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Bateman EA, Pripotnev S, Larocerie-Salgado J, Ross DC, Miller TA. Assessment, management, and rehabilitation of traumatic peripheral nerve injuries for non-surgeons. Muscle Nerve 2024. [PMID: 39030747 DOI: 10.1002/mus.28185] [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: 01/22/2024] [Revised: 05/28/2024] [Accepted: 06/02/2024] [Indexed: 07/22/2024]
Abstract
Electrodiagnostic evaluation is often requested for persons with peripheral nerve injuries and plays an important role in their diagnosis, prognosis, and management. Peripheral nerve injuries are common and can have devastating effects on patients' physical, psychological, and socioeconomic well-being; alongside surgeons, electrodiagnostic medicine specialists serve a central function in ensuring patients receive optimal treatment for these injuries. Surgical intervention-nerve grafting, nerve transfers, and tendon transfers-often plays a critical role in the management of these injuries and the restoration of patients' function. Increasingly, nerve transfers are becoming the standard of care for some types of peripheral nerve injury due to two significant advantages: first, they shorten the time to reinnervation of denervated muscles; and second, they confer greater specificity in directing motor and sensory axons toward their respective targets. As the indications for, and use of, nerve transfers expand, so too does the role of the electrodiagnostic medicine specialist in establishing or confirming the diagnosis, determining the injury's prognosis, recommending treatment, aiding in surgical planning, and supporting rehabilitation. Having a working knowledge of nerve and/or tendon transfer options allows the electrodiagnostic medicine specialist to not only arrive at the diagnosis and prognosticate, but also to clarify which nerves and/or muscles might be suitable donors, such as confirming whether the branch to supinator could be a nerve transfer donor to restore distal posterior interosseous nerve function. Moreover, post-operative testing can determine if nerve transfer reinnervation is occurring and progress patients' rehabilitation and/or direct surgeons to consider tendon transfers.
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Affiliation(s)
- Emma A Bateman
- Parkwood Institute, St Joseph's Health Care London, London, Canada
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Stahs Pripotnev
- Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | | | - Douglas C Ross
- Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Thomas A Miller
- Parkwood Institute, St Joseph's Health Care London, London, Canada
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Canada
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Bertelli JA, Tuffaha S, Sporer M, Seltser A, Cavalli E, Soldado F, Hill E. Distal nerve transfers for peripheral nerve injuries: indications and outcomes. J Hand Surg Eur Vol 2024; 49:721-733. [PMID: 38296247 DOI: 10.1177/17531934231226169] [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: 06/01/2024]
Abstract
Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.
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Affiliation(s)
- Jayme A Bertelli
- Department of Surgery, Federal University of Santa Catarina, Florianópolis, Brazil
- Department of Orthopedics and Traumatology, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Sami Tuffaha
- Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthias Sporer
- Department of Plastic Surgery, Academic Teaching Hospital Feldkirch, Austria
| | - Anna Seltser
- Department of Hand Surgery and Microsurgery Unit, Sheba Medical Center, Affiliated to Sackler School of Medicine, Tel Aviv University, Tel Hashomer, Ramat Gan, Israel
| | - Erica Cavalli
- Department of Plastic and Hand Surgery, IRCCS San Gerardo dei Tintori, Monza (MB), Italy
| | - Francisco Soldado
- Hospital Infantil Universitario Vall d'Hebron, Barcelona, Spain
- Hospital Infantil Universitario HM Nens, Barcelona, Spain
| | - Elspeth Hill
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Goubier JN, Battiston B, Casanas J, Quick T. Adult traumatic brachial plexus injuries: advances and current updates. J Hand Surg Eur Vol 2024; 49:734-746. [PMID: 38366385 DOI: 10.1177/17531934241229201] [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: 02/18/2024]
Abstract
Nerve grafting, tendon transfer and joint fusion are routinely used to improve the upper limb function in patients with brachial plexus palsies. Newer techniques have been developed that provide additional options for reconstruction. Nerve transfer is a tool for restoring upper limb function in total root avulsions where nerve grafting is not possible. In partial brachial plexus injuries, nerve transfers can greatly improve shoulder, elbow, wrist and hand function. Intraoperative electrical stimulation can be used to diagnose precisely which nerve is injured and to choose which nerve fascicles should be transferred. Finally, measuring the postoperative outcome can improve the evaluation of our techniques. The aim of this article was to present the current techniques used to treat patients with brachial plexus injury.
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Affiliation(s)
- Jean-Noel Goubier
- Brachial Plexus and Nerve Surgery Institute, Paris, France
- Hôpital Privé Paul d'Égine, Clinique la Francilienne, Champigny sur Marne, France
- Institut de la Main, Clinique Bizet, Paris, France
| | - Bruno Battiston
- UOD Reconstructive Microsurgery, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Tom Quick
- Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK
- Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital, Stanmore, UK
- Centre for Nerve Engineering, University College London, London, UK
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McMorrow LA, Czarnecki P, Reid AJ, Tos P. Current perspectives on peripheral nerve repair and management of the nerve gap. J Hand Surg Eur Vol 2024; 49:698-711. [PMID: 38603601 DOI: 10.1177/17531934241242002] [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: 04/13/2024]
Abstract
From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.
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Affiliation(s)
- Liam A McMorrow
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Piotr Czarnecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, Poznań, Poland
| | - Adam J Reid
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Pierluigi Tos
- Azienda Socio Sanitaria Territoriale Gaetano Pini, Milan, Italy
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Noor MS, Khabyeh-Hasbani N, Behbahani M, Koehler SM. Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique. Childs Nerv Syst 2024; 40:1159-1167. [PMID: 38353693 DOI: 10.1007/s00381-023-06270-y] [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: 12/13/2023] [Accepted: 12/23/2023] [Indexed: 03/28/2024]
Abstract
PURPOSE Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD. METHODS We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients. RESULTS At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD. CONCLUSION In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.
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Affiliation(s)
- Md Sibat Noor
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | | | - Mandana Behbahani
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA
| | - Steven M Koehler
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA.
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Crowe CS, Spinner RJ, Shin AY. Global trends and outcomes of nerve transfers for treatment of adult brachial plexus injuries. J Hand Surg Eur Vol 2024:17531934241232062. [PMID: 38372245 DOI: 10.1177/17531934241232062] [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] [Indexed: 02/20/2024]
Abstract
The presentation, management and outcomes of brachial plexus injuries are likely to be subject to regional differences across the globe. A comprehensive literature search was performed to identify relevant articles related to spinal accessory to suprascapular, intercostal to musculocutaneous, and ulnar and/or median nerve fascicle to biceps and/or brachialis motor branch nerve transfers for treatment of brachial plexus injuries. A total of 6007 individual brachial plexus injuries were described with a mean follow-up of 38 months. The specific indication for accessory to suprascapular and intercostal to musculocutaneous transfers were considerably different among regions (e.g. upper plexus vs. pan-plexal), while uniform for fascicular transfer for elbow flexion (e.g. upper plexus +/- C7). Similarly, functional recovery was highly variable for accessory to suprascapular and intercostal to musculocutaneous transfers, while British Medical Research Council grade ≥3 strength after fascicular transfer for elbow flexion was frequently obtained. Overall, differences in outcomes seem to be inherent to the specific transfer being utilized.Level of evidence: III.
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Affiliation(s)
- Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
| | | | - Alexander Y Shin
- Division of Hand Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, MN, USA
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Bahm J, Beier JP, Schäfer B. [Contralateral C7 Nerve Transfer]. HANDCHIR MIKROCHIR P 2024; 56:74-83. [PMID: 38408481 DOI: 10.1055/a-2246-1704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Complex brachial plexus injuries with multiple or complete root avulsions make intraplexic reconstruction impossible in some cases. Such cases necessitate the use of extraplexic nerve donors such as the spinal accessory nerve or intercostal nerves. The contralateral C7 root represents a donor with a high axon count and can be used as an axon source in such cases. We summarise current indications, surgical technique and functional results after a contralateral C7 transfer in cases of brachial plexus injury, describing some of our own cases and including a selective literature review.
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Affiliation(s)
- Jörg Bahm
- Klinik für Plastische Chirurgie, Hand- und Verbrennungschirurgie, Sektion für Plexuschirurgie, Universitätsklinikum Aachen, Aachen, Germany
| | - Justus P Beier
- Klinik für Plastische Chirurgie, Hand- und Verbrennungschirurgie, Uniklinik RWTH Aachen, Aachen, Germany
| | - Benedikt Schäfer
- Klinik für Plastische Chirurgie, Hand- und Verbrennungschirurgie, Sektion für Plexuschirurgie, Universitätsklinikum Aachen, Aachen, Germany
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Kakinoki R, Ohtani K, Ohta S, Ikeguchi R, Akagi M, Goto K. Treatment of Complete Brachial Plexus Injuries Using Double Free Muscle Transfer. J Hand Surg Am 2023:S0363-5023(23)00497-5. [PMID: 37921713 DOI: 10.1016/j.jhsa.2023.09.005] [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: 04/13/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE The purpose of this study was to examine the surgical outcomes of double free muscle transfer (DFMT) performed in patients with complete brachial plexus injury (BPI). METHODS We retrospectively analyzed the outcomes of DFMT for 12 patients with complete BPI who were followed up for more than 2 years after the final muscle transplantation. Their mean age was 29 years (range, 18-41). Three patients underwent contralateral C7 nerve root transfer before the DFMT. The range of motion (ROM) of the shoulder, elbow, and fingers was measured. Patient-reported outcome measures, including Disability of the Shoulder, Arm, and Hand (DASH) scores and visual analog scale (VAS) scores for pain, were also examined. RESULTS The mean shoulder ROM against gravity was 22° ± 8° in abduction and 33° ± 5° in flexion. Seven patients underwent phrenic nerve (PhN) transfer to the suprascapular nerves, and five exhibited asymptomatic lung impairment on spirography more than 2 years after PhN transfer. The mean elbow ROM against gravity was 111° ± 9° in flexion and -32° ± 7° in extension. All patients obtained elbow flexion >90° against a 0.5-kg weight. All patients obtained touch sensation and two recognized warm and cold sensations in the affected palm. The mean total active motion of the affected fingers was 44° ± 11°. All patients exhibited hook function of the hands. The mean preoperative and postoperative DASH scores were 70.3 ± 13.4 and 51.8 ± 15.9, respectively. The mean pain VAS score was 28 ± 31 at the final follow-up. CONCLUSIONS Double free muscle transfer provided patients with complete brachial plexus palsy with good elbow flexion and hand hook functions. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ryosuke Kakinoki
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan.
| | - Kazuhiro Ohtani
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
| | - Souichi Ohta
- Department of Orthopedic Surgery, Kansai Electric Power Hospital, Osaka, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masao Akagi
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
| | - Koji Goto
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
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Jimulia DT, Duraku LS, Parekh JN, George S, Chaudhry T, Power DM. The Clinical Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Through a Posterior Approach. Hand (N Y) 2023:15589447231199797. [PMID: 37746731 DOI: 10.1177/15589447231199797] [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] [Indexed: 09/26/2023]
Abstract
BACKGROUND Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer can restore function to the rotator cuff following brachial plexus injuries. The traditional anterior approach using the lateral branch of the SAN causes denervation of the lateral trapezius limiting shoulder elevation. Suprascapular nerve pathology at the suprascapular notch may be missed resulting in poor reinnervation of the rotator cuff. The posterior approach uses the medial SAN and allows decompression and visualization of the SSN at the notch and nerve transfer coaptation closer to the target muscles with a shorter reinnervation distance. METHODS This is a review of 28 patients from 2014 to February 2020 who underwent SAN to SSN nerve transfer via a posterior approach. Patients were evaluated for SSN pathology, external rotation power, and range of motion. Data were evaluated for high-energy trauma (HET) and low-energy trauma/nontraumatic etiology subsets. RESULTS A total of 8 HET (40%) patients had pathology identified at the suprascapular notch during the posterior approach, including SSN scarring, ruptures, neuromata-in-continuity, and ossification of ligaments. British Medical Research Council grade greater than or equal to 4 shoulder external rotation was achieved in 75% patients with median range of motion 137.5°. CONCLUSIONS Spinal accessory nerve to SSN transfer using a posterior approach allows visualization of pathology involving the SSN and coaptation of a medial SAN transfer close to the target muscles. Following HET, 8 cases (40%) had posterior pathology identified. Spinal accessory nerve to SSN transfer through a posterior approach shows improved external rotation power and range of motion.
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Affiliation(s)
- Devanshi T Jimulia
- Brachial Plexus and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
- HaPPeN Research Network, Birmingham, UK
| | - Liron S Duraku
- Brachial Plexus and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
- HaPPeN Research Network, Birmingham, UK
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, The Netherlands
| | - Jvalant N Parekh
- Brachial Plexus and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
| | - Samuel George
- Brachial Plexus and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
- HaPPeN Research Network, Birmingham, UK
| | - Tahseen Chaudhry
- Brachial Plexus and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
- HaPPeN Research Network, Birmingham, UK
| | - Dominic M Power
- Brachial Plexus and Peripheral Nerve Injury Service, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, UK
- HaPPeN Research Network, Birmingham, UK
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Tahir H, Osama M, Beg MSA, Ahmed M. Comparison of Anterior vs. Dorsal Approach for Spinal Accessory to Suprascapular Nerve Transfer in Patients With a Brachial Plexus Injury and Its Outcome on Shoulder Function. Cureus 2022; 14:e26543. [PMID: 35936186 PMCID: PMC9346609 DOI: 10.7759/cureus.26543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Brachial plexus injuries are frequently encountered in the domain of plastic surgery, mostly secondary to road traffic accidents, gunshot injuries, or falls from a height. Many modalities have been described in the management, depending on the level and duration of the injury. C5, C6 and C5, C6, C7 are two common patterns in which nerve repair and transfers are described. At our center, we practice spinal accessory to suprascapular nerve transfer in all patients with upper trunk brachial plexus injury. There are two described approaches for the spinal accessory nerve to suprascapular nerve transfer, i.e. anterior or dorsal. The rationale for doing the posterior approach is that this approach avoids damaging the suprascapular nerve at its entrance in the suprascapular notch under the suprascapular ligament during exploration due to traction. Materials and methods This is a retrospective study with a consecutive sampling of 23 patients presenting at Liaquat National Hospital, Karachi, with upper trunk brachial plexus injuries during the time period from January 2016 to December 2017, i.e. two years. We divided these 23 patients into two groups, one with the anterior approach and the other with a dorsal approach for spinal accessory to suprascapular nerve transfer for shoulder abduction. The mean duration of post-surgical follow-up was from 18 to 24 months and recovery and functional outcomes were assessed. Results Out of the 23 patients that were included, 10 patients were operated on with an anterior approach and 13 with a posterior approach. Fifty percent (50%) of patients operated with the anterior approach and 84% of patients with the posterior showed the best motor grade recovery of M4, respectively, with better performance in patients with the posterior approach as compared to the anterior approach. Conclusion We advocate taking a posterior approach for spinal accessory to suprascapular nerve transfer for shoulder abduction, as it has shown better results with reliable outcomes concerning shoulder abduction, angle of abduction, and range of motion.
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Viswamadesh R, Rajendiran S, Pakiri Maheswaran AM, Gomathinayagam K. The Demography of Traumatic Brachial Plexus Avulsion Injuries. Cureus 2022; 14:e25626. [PMID: 35795508 PMCID: PMC9250756 DOI: 10.7759/cureus.25626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background and objective Brachial plexus injuries more commonly affect the younger generation who constitute the productive workforce. The patients who sustain avulsion injuries of the brachial plexus are more often involved in high-velocity accidents. The avulsion injuries are surgically managed by nerve transfers. This study aimed to evaluate the demography of brachial plexus avulsion injuries. Materials and methods This retrospective study was conducted in January 2013 and included 21 patients treated from January 2007 to December 2011. Results Of the 21 patients, 20 were male and the most commonly affected patients were in the age group of 21-30 years. The mean age of the affected patients was 27.24 years. Six of the patients had pan palsy (C5-8 and T1), nine had C5-7 injury, and six had C5-6 injury. Twenty patients underwent spinal accessory to suprascapular nerve transfer, nine patients underwent ulnar nerve fascicle to nerve to biceps branch transfer, and one patient underwent intercostal nerve to musculocutaneous nerve transfer. Of note, 40% of the patients regained more than M3 power for abduction and external rotation of the shoulder, and 30% of the patients regained more than M3 power for elbow function. Conclusions Road traffic accidents are the most common cause of brachial plexus injuries. Nerve transfers for shoulder and elbow function play a significant role in improving the function of the upper extremity.
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Power DM, Jimulia D, Malone P, Shirley C, Chaudhry T. Pathological findings identified during the posterior approach to the spinal accessory nerve after high-energy trauma. J Hand Surg Eur Vol 2022; 47:393-398. [PMID: 34472393 DOI: 10.1177/17531934211039698] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The spinal accessory to suprascapular nerve transfer is a key procedure for restoring shoulder function in upper brachial plexus injuries and is typically undertaken via an anterior approach. The anterior approach may miss injury to the suprascapular nerve about the suprascapular notch, which may explain why functional outcomes are often limited. In 2014 we adopted a posterior approach to enable better visualization of the suprascapular nerve at the notch. Over the next 6 years we have used this approach for 20 explorations after high-energy trauma. In 7/20 we identified abnormalities at the level of the suprascapular ligament, which we would not have identified with an anterior approach: there were two ruptures, two neuromas-in-continuity and three cases of scar encasement, necessitating neurolysis. Nerve transfer could be undertaken distal to the suprascapular notch, bypassing the site of injury. These pathological findings support the wider adoption of the posterior approach in cases of high-energy trauma.Level of evidence: IV.
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Affiliation(s)
- Dominic M Power
- Brachial Plexus and Peripheral Nerve Injury Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Devanshi Jimulia
- Brachial Plexus and Peripheral Nerve Injury Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Malone
- Brachial Plexus and Peripheral Nerve Injury Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colin Shirley
- Brachial Plexus and Peripheral Nerve Injury Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tahseen Chaudhry
- Brachial Plexus and Peripheral Nerve Injury Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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13
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Bertelli JA, Ghizoni MF. Reconstruction of C5-C8 (T1 Hand) Brachial Plexus Paralysis in a Series of 52 Patients. J Hand Surg Am 2022; 47:237-246. [PMID: 35012795 DOI: 10.1016/j.jhsa.2021.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 08/30/2021] [Accepted: 11/03/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE A C5-C8 brachial plexus root injury, also known as a T1 hand, is associated with paralysis of shoulder abduction or external rotation and elbow flexion, accompanied by variable elbow, wrist, thumb, or finger extension deficits. We report the results of reconstruction for C5-C8 brachial plexus paralysis in 52 patients operated upon within 12 months of injury and having at least 24 months of follow-up. METHODS We considered surgery to be indicated if, by the fifth month after trauma, shoulder abduction and external rotation and elbow flexion remained paralyzed. Root grafting was possible in 35% of the patients and was performed concomitantly with nerve transfers. Shoulder motion was reconstructed by transferring the spinal accessory to the suprascapular nerve. Elbow flexion was restored by transferring fascicles from either the median or ulnar nerve to the biceps motor branch. When needed, elbow extension was reconstructed by transferring 1 motor branch of the flexor carpi ulnaris to the triceps lower medial head motor branch. Wrist extension was restored by transferring the distal anterior interosseous nerve to the extensor carpi radialis brevis motor branch. RESULTS Within 12 months of injury, we observed preserved or spontaneous recovery of elbow, wrist, finger, and thumb extension in 25%, 12%, 50%, and 68% of patients, respectively. After surgical reconstruction, improved range of motion for shoulder, elbow flexion, and wrist extension scoring at least M3 was present in 90% of our patients. All 10 patients in whom a motor branch of the flexor carpi ulnaris was used for triceps reconstruction recovered elbow extension, while flexor carpi ulnaris function was preserved. CONCLUSIONS In approximatively 90% of our patients, distal nerve transfers resulted in functional recovery of shoulder abduction, elbow flexion or extension, and wrist extension. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jayme A Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil; Department of Neurosurgery, Nossa Senhora da Conceição Hospital, Tubarão, Santa Catarina, Brazil.
| | - Marcos F Ghizoni
- Department of Neurosurgery, Nossa Senhora da Conceição Hospital, Tubarão, Santa Catarina, Brazil
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Saltzman EB, Krishnan K, Winston MJ, Das De S, Lee SK, Wolfe SW. A Cadaveric Study on the Utility of the Levator Scapulae Motor Nerve as a Donor for Brachial Plexus Reconstruction. J Hand Surg Am 2021; 46:812.e1-812.e5. [PMID: 33487489 DOI: 10.1016/j.jhsa.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 09/30/2020] [Accepted: 11/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the utility of the levator scapulae motor nerve (LSN) as a donor nerve for brachial plexus nerve transfer. We hypothesized that the LSN could be transferred to the suprascapular nerve (SSN) or long thoracic nerve (LTN) with a reliable tension-free coaptation and appropriate donor-to-recipient axon count ratio. METHODS Twelve brachial plexus dissections were performed on 6 adult cadavers, bilaterally. We identified the LSN, spinal accessory nerve (SAN), SSN, and LTN. Each nerve was prepared for transfer and nerve redundancies were calculated. Cross-sections of each nerve were examined histologically, and axons counted. We transferred the LSN to target first the SSN and then the LTN, in a tension-free coaptation. For reference, we transferred the distal SAN to target the SSN and LTN and compared transfer parameters. RESULTS Three cadavers demonstrated 2 LSN branches supplying the levator scapulae. The axon count ratio of donor-to-recipient nerve was 1:4.0 (LSN:SSN) and 1:2.1 (LSN:LTN) for a single LSN branch and 1:3.0 (LSN:SSN) and 1:1.6 (LSN:LTN) when 2 LSN branches were available. Comparatively, the axon count ratio of donor-to-recipient nerve was 1:2.5 and 1:1.3 for the SAN to the SSN and the LTN, respectively. The mean redundancy from the LSN to the SSN and the LTN was 1.7 cm (SD, 3.1 cm) and 2.9 cm (SD, 2.8 cm), and the redundancy from the SAN to the SSN and the LTN was 4.5 (SD, 0.7 cm) and 0.75 cm (SD, 1.0 cm). CONCLUSIONS These data support the use of the LSN as a potential donor for direct nerve transfer to the SSN and LTN, given its adequate redundancy and size match. CLINICAL RELEVANCE The LSN should be considered as an alternative nerve donor source for brachial plexus reconstruction, especially in 5-level injuries with scarce donor nerves. If used in lieu of the SAN during primary nerve reconstruction, trapezius tendon transfer for improved external rotation would be enabled.
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Affiliation(s)
- Eliana B Saltzman
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Karthik Krishnan
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY
| | - Mark J Winston
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Soumen Das De
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Steve K Lee
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY
| | - Scott W Wolfe
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY.
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Kluemper C, Aversano M, Kozin S, Zlotolow DA. Long Thoracic Nerve Transfer for Children With Brachial Plexus Injuries. J Pediatr Orthop 2021; 41:374-378. [PMID: 34096554 DOI: 10.1097/bpo.0000000000001774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The transfer of intraplexal and extraplexal nerves for restoration of function in children with traumatic and birth brachial plexus palsies has become well accepted. Little has been written about using the long thoracic nerve (LTN) as a donor in reanimation of the upper extremity. The authors present a case series of nerve transfers using the LTN as a donor in brachial plexus injury. METHODS A retrospective chart review was performed over a 10-year period at a single institution. The primary outcome measure was the active movement scale. RESULTS Fourteen patients were included in the study: 10 birth injury patients and 4 blunt trauma patients. Average follow-up time was 21.3 and 10.75 months, respectively. The best outcomes were seen when the LTN was used for reinnervation of the obturator nerve in free functioning muscle transfers. The next most successful recipients were the musculocutaneous and axillary nerves. Outcomes were poor in transfers to the posterior interosseous fascicles of the radial nerve and the radial nerve branches to the triceps. DISCUSSION The LTN may be a potential nerve donor for musculocutaneous or axillary nerve reinnervation in patients with brachial plexus injuries when other donors are not available during a primary plexus reconstruction. However, the best use may be for delayed neurotization of a free functioning muscle transfer after the initial plexus reconstruction has failed and no other donors are available. LEVEL OF EVIDENCE Level IV-therapeutic study.
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Affiliation(s)
| | | | - Scott Kozin
- Shriners Hospital for Children, Philadelphia, PA
| | - Dan A Zlotolow
- Philadelphia Hand to Shoulder Center.,Shriners Hospital for Children, Philadelphia, PA
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Kaiser R, Krajcová A, Makel M, Ullas G, Němcová V. Anatomical aspects of the selective infraspinatus muscle neurotization by spinal accessory nerve. J Plast Surg Hand Surg 2020; 55:220-225. [PMID: 33317372 DOI: 10.1080/2000656x.2020.1856680] [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] [Indexed: 10/22/2022]
Abstract
The suprascapular nerve (SSN) is commonly reconstructed by spinal accessory nerve (SAN) transfer. However, reinnervation of its branch to the infraspinatus muscle (IB-SSN) is poor. Reconstruction of the SSN in cases of scapular fractures is frequently neglected in clinical practice. The morphological study was performed on 25 adult human cadavers. The course and the length of SSN of minimal diameter of 2 mm within the trapezius muscle, the length of the distal stump of IB-SSN to its branching point and the length of the SSN available for reconstructive procedure were measured. The feasibility study of the SAN - IB-SSN neurotization performed by using a bony canal under the spine of scapula was performed. The mean distance of the SAN from the spine was 8.5 cm (±0.88) at the point where it perforates the trapezius muscle and 4.49 cm (±0.72) at the most distal part of the nerve. The mean length of the intramuscular portion of the nerve was 14.74 cm (±1.99). It ran under a mean latero-medial angle of 15.54° (±2.51). The mean distance between the medial end of the scapular spine and the SAN was 2.44 cm (± 0.64). The mean length of the IB-SSN was 3.6 cm (± 0.67). The mean length of the SAN stump which was mobilized from its original course and transferred to the infraspinous fossa to reach distal stump of the IB-SSN was 8.09 cm (±1.6). Direct SAN to IB-SSN transfer is anatomically feasible in the adult population.
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Affiliation(s)
- Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic
| | - Aneta Krajcová
- Department of Plastic Surgery, First Faculty of Medicine, Charles University and Hospital Na Bulovce, Prague, Czech Republic.,Department of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Michal Makel
- Department of Plastic Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Gautham Ullas
- Department of ENT, James Cook University Hospital, Middlesbrough, UK
| | - Veronika Němcová
- Department of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
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Transfer of the rhomboid nerve for restoration of shoulder external rotation in partial brachial plexus palsy. Injury 2020; 51 Suppl 4:S84-S87. [PMID: 32067773 DOI: 10.1016/j.injury.2020.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/08/2020] [Indexed: 02/02/2023]
Abstract
Restoration of shoulder external rotation in partial brachial plexus palsies is a real challenge. The transfer of the spinal accessory nerve to the suprascapular nerve remains the gold standard. This transfer, however, cannot be always performed. Therefore, in these cases, we previously proposed the transfer of the rhomboid nerve to the suprascapular nerve through a posterior approach. The goal of the present study is to assess this technique through a short series. Eight male patients had a partial plexus palsy. Five patients had C5, C6 root injuries, two patients had C5, C6, C7 root injuries, and one patient had C5 to C8 root injuries. No patients had C5 or C6 root avulsions. In one patient, the spinal accessory nerve was injured and in seven patients, the proximal suprascapular nerve was not available. All patients underwent a transfer from the rhomboid nerve to the suprascapular nerve. Concerning shoulder elevation, transfers from the branch of the long head of the triceps or ulnar nerve fascicle were transferred to the axillary nerve. For elbow flexion, fascicles from the ulnar nerve, median nerve, or both were used. For elbow extension, three intercostal nerves in one patient and one fascicle from the ulnar nerve in two patients were transferred to the branch of the long head of the triceps. For wrist and finger extension, palliative surgery was proposed. All patients recovered external shoulder rotation (from 70-110º) and shoulder elevation (range, 80-140º). Active elbow flexion was coded M4 in seven patients and M3 in one patient. All patients recovered active elbow extension. The transfer of the rhomboid nerve to the suprascapular nerve is an efficient procedure for shoulder external rotation in partial brachial plexus palsies without C5 root avulsion. The results in terms of range-of-motion are, however, poorer than with the spinal accessory nerve. Therefore, this technique is appropriate if the spinal accessory nerve is injured or if the suprascapular nerve is not available in the cervical area. This technique must be associated with another transfer to the axillary nerve for shoulder elevation. The study of more patients will be necessary to confirm these results.
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Yamauti LS, Simão DT, Rodrigues JC, Kimura LK, Mattar Junior R. ANALYSIS OF FATTY DEGENERATION OF THE TRAPEZIUS MUSCLE AFTER USE OF ACCESSORY NERVE. ACTA ORTOPEDICA BRASILEIRA 2020; 28:186-189. [PMID: 32788861 PMCID: PMC7405843 DOI: 10.1590/1413-785220202804233302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To investigate, through magnetic resonance imaging, the occurrence of fatty
degeneration of the trapezius in adult patients undergoing nerve transfer
procedure, using the spinal accessory nerve. Methods: A total of 13 patients meeting the criteria of unilateral brachial plexus
injury and more than one year of postoperative care after nerve transfer
surgery underwent an MRI scan of the trapezius. A T1-weighted 3D sequence
was used, with the IDEAL technique using 8.0 mm cut thickness, 8.0 mm cut
spacing, TR of 100 ms, TE of 3.45 ms, flip angle of 10 degrees, 20 cuts, on
the sagittal plane. The images of the upper, transverse and lower parts of
the trapezius muscle were then classified according to the degree of fatty
degeneration, compared with the contralateral side, using the Goutallier
score. Results: For the upper trapezius there was a change of the degeneration state in 23%
(p = 0.083), for the transverse section there was a change in 84.6% (p =
0.003), for the lower one there was a change in 92.3% (p = 0.002). Conclusion: The upper trapezius did not undergo significant degeneration after transfer.
The lower and transverse trapezius suffered fatty degeneration in most
patients, indicating severe functional impairment. Level of Evidence
IV, Case series.
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Li L, Yang J, Qin B, Wang H, Yang Y, Fang J, Chen G, Liu X, Tu Z, Gu L. Analysis of human acellular nerve allograft combined with contralateral C7 nerve root transfer for restoration of shoulder abduction and elbow flexion in brachial plexus injury: a mean 4-year follow-up. J Neurosurg 2020; 132:1914-1924. [PMID: 31026835 DOI: 10.3171/2019.2.jns182620] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/05/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Human acellular nerve allograft applications have increased in clinical practice, but no studies have quantified their influence on reconstruction outcomes for high-level, greater, and mixed nerves, especially the brachial plexus. The authors investigated the functional outcomes of human acellular nerve allograft reconstruction for nerve gaps in patients with brachial plexus injury (BPI) undergoing contralateral C7 (CC7) nerve root transfer to innervate the upper trunk, and they determined the independent predictors of recovery in shoulder abduction and elbow flexion. METHODS Forty-five patients with partial or total BPI were eligible for this retrospective study after CC7 nerve root transfer to the upper trunk using human acellular nerve allografts. Deltoid and biceps muscle strength, degree of shoulder abduction and elbow flexion, Semmes-Weinstein monofilament test, and static two-point discrimination (S2PD) were examined according to the modified British Medical Research Council (mBMRC) scoring system, and disabilities of the arm, shoulder, and hand (DASH) were scored to establish the function of the affected upper limb. Meaningful recovery was defined as grades of M3-M5 or S3-S4 based on the scoring system. Subgroup analysis and univariate and multivariate logistic regression analyses were conducted to identify predictors of human acellular nerve allograft reconstruction. RESULTS The mean follow-up duration and the mean human acellular nerve allograft length were 48.1 ± 10.1 months and 30.9 ± 5.9 mm, respectively. Deltoid and biceps muscle strength was grade M4 or M3 in 71.1% and 60.0% of patients. Patients in the following groups achieved a higher rate of meaningful recovery in deltoid and biceps strength, as well as lower DASH scores (p < 0.01): age < 20 years and age 20-29 years; allograft lengths ≤ 30 mm; and patients in whom the interval between injury and surgery was < 90 days. The meaningful sensory recovery rate was approximately 70% in the Semmes-Weinstein monofilament test and S2PD. According to univariate and multivariate logistic regression analyses, age, interval between injury and surgery, and allograft length significantly influenced functional outcomes. CONCLUSIONS Human acellular nerve allografts offered safe reconstruction for 20- to 50-mm nerve gaps in procedures for CC7 nerve root transfer to repair the upper trunk after BPI. The group in which allograft lengths were ≤ 30 mm achieved better functional outcome than others, and the recommended length of allograft in this procedure was less than 30 mm. Age, interval between injury and surgery, and allograft length were independent predictors of functional outcomes after human acellular nerve allograft reconstruction.
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20
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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: 10] [Impact Index Per Article: 2.5] [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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21
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Li L, He WT, Qin BG, Liu XL, Yang JT, Gu LQ. Comparison between direct repair and human acellular nerve allografting during contralateral C7 transfer to the upper trunk for restoration of shoulder abduction and elbow flexion. Neural Regen Res 2019; 14:2132-2140. [PMID: 31397352 PMCID: PMC6788224 DOI: 10.4103/1673-5374.262600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Direct coaptation of contralateral C7 to the upper trunk could avoid the interposition of nerve grafts. We have successfully shortened the gap and graft lengths, and even achieved direct coaptation. However, direct repair can only be performed in some selected cases, and partial procedures still require autografts, which are the gold standard for repairing neurologic defects. As symptoms often occur after autografting, human acellular nerve allografts have been used to avoid concomitant symptoms. This study investigated the quality of shoulder abduction and elbow flexion following direct repair and acellular allografting to evaluate issues requiring attention for brachial plexus injury repair. Fifty-one brachial plexus injury patients in the surgical database were eligible for this retrospective study. Patients were divided into two groups according to different surgical methods. Direct repair was performed in 27 patients, while acellular nerve allografts were used to bridge the gap between the contralateral C7 nerve root and upper trunk in 24 patients. The length of the harvested contralateral C7 nerve root was measured intraoperatively. Deltoid and biceps muscle strength, and degrees of shoulder abduction and elbow flexion were examined according to the British Medical Research Council scoring system; meaningful recovery was defined as M3–M5. Lengths of anterior and posterior divisions of the contralateral C7 in the direct repair group were 7.64 ± 0.69 mm and 7.55 ± 0.69 mm, respectively, and in the acellular nerve allografts group were 6.46 ± 0.58 mm and 6.43 ± 0.59 mm, respectively. After a minimum of 4-year follow-up, meaningful recoveries of deltoid and biceps muscles in the direct repair group were 88.89% and 85.19%, respectively, while they were 70.83% and 66.67% in the acellular nerve allografts group. Time to C5/C6 reinnervation was shorter in the direct repair group compared with the acellular nerve allografts group. Direct repair facilitated the restoration of shoulder abduction and elbow flexion. Thus, if direct coaptation is not possible, use of acellular nerve allografts is a suitable option. This study was approved by the Medical Ethical Committee of the First Affiliated Hospital of Sun Yat-sen University, China (Application ID: [2017] 290) on November 14, 2017.
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Affiliation(s)
- Liang Li
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wen-Ting He
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ben-Gang Qin
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiao-Lin Liu
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jian-Tao Yang
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Li-Qiang Gu
- Department of Orthopedic Trauma and Microsurgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
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22
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Le Hanneur M, Masmejean EH, Lafosse T. Direct transfer of C7 pectoral fascicles to the suprascapular nerve in C5/C6 brachial plexus palsies: an anatomical study. J Hand Surg Eur Vol 2019; 44:628-631. [PMID: 30871404 DOI: 10.1177/1753193419835436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We investigated a technique to reconstruct the suprascapular nerve in patients with C5/C6 brachial plexus palsies, using pectoral fascicles from the ipsilateral C7 root. Using a supraclavicular approach in eight cadavers, the suprascapular nerve was placed side by side with an anterior quadrant fascicle from the C7 root. Several criteria were assessed, including the fascicle length, the overlap between the two nerves and their respective diameters. The mean length of the C7 fascicles was 19.3 mm, with a mean overlap of 4.7 mm. The suprascapular nerve and the C7 fascicles had mean diameters of 2.2 mm and 2.1 mm, respectively. Pectoral fascicles from C7 seem to be an option for reconstruction of the suprascapular nerve in C5/C6 palsies. Clinical studies will be required to establish the potential limitations of this transfer, especially in cases with complex lesions of the suprascapular nerve.
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Affiliation(s)
- Malo Le Hanneur
- 1 Department of Orthopedics and Traumatology - Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Paris, France
| | - Emmanuel H Masmejean
- 1 Department of Orthopedics and Traumatology - Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Paris, France
| | - Thibault Lafosse
- 1 Department of Orthopedics and Traumatology - Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Paris, France.,2 Hand, Upper Limb, Brachial plexus, and Microsurgery Unit (PBMA), Clinique Générale d'Annecy, Annecy, France
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Tavares PL, Siqueira MG, Martins RS, Zaccariotto M, Foroni L, Heise CO, Solla D. Restoration of shoulder external rotation by means of the infraspinatus muscle reinnervation with a radial nerve branch transfer. Br J Neurosurg 2019; 34:552-558. [DOI: 10.1080/02688697.2019.1630549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Paulo L. Tavares
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Mario G. Siqueira
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Roberto S. Martins
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Monise Zaccariotto
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Luciano Foroni
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
| | - Carlos O. Heise
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
- Clinical Neurophysiology, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Davi Solla
- Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil
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Texakalidis P, Tora MS, Lamanna JJ, Wetzel J, Boulis NM. 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. World Neurosurg 2019; 126:e1251-e1256. [PMID: 30898759 DOI: 10.1016/j.wneu.2019.03.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Muhibullah S Tora
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jason J Lamanna
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeremy Wetzel
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas M Boulis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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25
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Bertelli JA, Soldado F, Rodrígues-Baeza A, Ghizoni MF. Transferring the Motor Branch of the Opponens Pollicis to the Terminal Division of the Deep Branch of the Ulnar Nerve for Pinch Reconstruction. J Hand Surg Am 2019; 44:9-17. [PMID: 30366737 DOI: 10.1016/j.jhsa.2018.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 07/24/2018] [Accepted: 07/24/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE With ulnar nerve injuries, paralysis of the first dorsal interosseous (FDI) and the adductor pollicis (ADP) muscles weakens pinch. The likelihood that these muscles will be reinnervated following ulnar nerve repair around the elbow is very low. To overcome this obstacle, we propose a more distal repair: transferring the opponens pollicis motor branch (OPB) to the terminal division of the deep branch of the ulnar nerve (TDDBUN). METHODS We dissected 10 embalmed hands to study the anatomy of the thenar branches of the median nerve and TDDBUN. We also operated on 3 patients with recent ulnar nerve injuries around the elbow, suturing the ulnar nerve and transferring the OPB to the TDDBUN. Before and after surgery, we measured grasp, key pinch, and pinch-to-zoom strength using dynamometers. Pinch-to-zoom gesture consists of moving the index finger and thumb pulp toward each other for zooming out of an image on screen. Patients were followed for at least 15 months. RESULTS The thenar branch of the median nerve innervated the abductor pollicis brevis and opponens pollicis in all specimens, but only half the superficial head of the flexor pollicis brevis. The TDDBUN gave off a single motor branch to the transverse head of the ADP, 1 or 2 branches to the oblique head, and a final branch to the FDI. The ratio of myelinated fibers between the OPB and the TDDBUN was 3:5. Relative to the normal side, pinch-to-zoom strength was mostly affected by the ulnar nerve lesion, with strength decreased by 80% to 90%. After surgery, we observed reinnervation of the FDI and an 80% to 90% improvement in pinch-to-zoom strength. CONCLUSIONS Transferring the OPB to the TDDBUN provided reinnervation of the FDI and ADP, thereby contributing to pinch strength improvement. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Jayme Augusto Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, SC, Brazil.
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
| | - Alfonso Rodrígues-Baeza
- Human Anatomy Unit, Morphologic Sciences Department, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcos Flávio Ghizoni
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, SC, Brazil
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Traumatic upper plexus palsy: Is the exploration of brachial plexus necessary? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:255-262. [DOI: 10.1007/s00590-018-2345-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 11/25/2018] [Indexed: 12/15/2022]
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Mihara A, Kanchiku T, Nishida N, Tagawa H, Ohgi J, Suzuki H, Imajo Y, Funaba M, Nakashima D, Chen X, Taguchi T. Biomechanical analysis of brachial plexus injury: Availability of three-dimensional finite element model of the brachial plexus. Exp Ther Med 2017; 15:1989-1993. [PMID: 29434794 PMCID: PMC5776614 DOI: 10.3892/etm.2017.5607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/02/2017] [Indexed: 11/25/2022] Open
Abstract
Adult brachial plexus injuries frequently lead to significant and permanent physical disabilities. Investigating the mechanism of the injury using biomechanical approaches may lead to further knowledge with regard to preventing brachial plexus injuries. However, there are no reports of biomechanical studies of brachial plexus injuries till date. Therefore, the present study used a complex three-dimensional finite element model (3D-FEM) of the brachial plexus to analyze the mechanism of brachial plexus injury and to assess the validity of the model. A complex 3D-FEM of the spinal column, dura mater, spinal nerve root, brachial plexus, rib bone and cartilage, clavicle, scapula, and humerus were conducted. Stress was applied to the model based on the mechanisms of clinically reported brachial plexus injuries: Retroflexion of the cervical, lateroflexion of the cervical, rotation of the cervical, and abduction of the upper limb. The present study analyzed the distribution and strength of strain applied to the brachial plexus during each motion. When the cervical was retroflexed or lateroflexed, the strain was focused on the C5 nerve root and the upper trunk of the brachial plexus. When the upper limb was abducted, strain was focused on the C7 and C8 nerve roots and the lower trunk of the brachial plexus. The results of brachial plexus injury mechanism corresponded with clinical findings that demonstrated the validity of this model. The results of the present study hypothesized that the model has a future potential for analyzing pathological conditions of brachial plexus injuries and other injuries or diseases, including that of spine and spinal nerve root.
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Affiliation(s)
- Atsushi Mihara
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Tsukasa Kanchiku
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Haruki Tagawa
- Department of Mechanical Engineering, Yamaguchi University, Ube, Yamaguchi 755-8505, Japan
| | - Junji Ohgi
- Department of Mechanical Engineering, Yamaguchi University, Ube, Yamaguchi 755-8505, Japan
| | - Hidenori Suzuki
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Yasuaki Imajo
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Daisuke Nakashima
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi 755-8505, Japan
| | - Xian Chen
- Department of Mechanical Engineering, Yamaguchi University, Ube, Yamaguchi 755-8505, Japan
| | - Toshihiko Taguchi
- Department of Mechanical Engineering, Yamaguchi University, Ube, Yamaguchi 755-8505, Japan
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Rhomboid nerve transfer to the suprascapular nerve for shoulder reanimation in brachial plexus palsy: A clinical report. HAND SURGERY & REHABILITATION 2016; 35:363-366. [PMID: 27781982 DOI: 10.1016/j.hansur.2016.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 06/08/2016] [Accepted: 07/03/2016] [Indexed: 11/24/2022]
Abstract
Recovery of shoulder function is a real challenge in cases of partial brachial plexus palsy. Currently, in C5-C6 root injuries, transfer of the long head of the triceps brachii branch is done to revive the deltoid muscle. Spinal accessory nerve transfer is typically used for reanimation of the suprascapular nerve. We propose an alternative technique in which the nerve of the rhomboid muscles is transferred to the suprascapular nerve. A 33-year-old male patient with a C5-C6 brachial plexus injury with shoulder and elbow flexion palsy underwent surgery 7 months after the injury. The rhomboid nerve was transferred to the suprascapular nerve and the long head of the triceps brachii branch to the axillary nerve for shoulder reanimation. A double transfer of fascicles was performed, from the ulnar and median nerves to the biceps brachii branch and brachialis branch, respectively, for elbow flexion. At 14 months' follow-up, elbow flexion was rated M4. Shoulder elevation was 85 degrees and rated M4, and external rotation was 80 degrees and rated M4. After performing a cadaver study showing that transfer of the rhomboid nerve to the suprascapular nerve is technically possible, here we report and discuss the clinical outcomes of this new transfer technique.
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