Successful recovery of sensation loss in upper brachial plexus injuries (original) (raw)
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Surgical outcomes following nerve transfers in upper brachial plexus injuries
Indian Journal of Plastic Surgery, 2009
Background: Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury. Materials and Methods: We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors-radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient). Results: Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50-170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).
Nerve Transfers in Adult Brachial Plexus Injuries
Advances in Spine Surgery [Working Title]
Brachial plexus injuries are semi-emergency conditions that require early intervention. Nerve transfers in adult brachial plexus injuries have become the standard treatment that gives reasonably good results if performed before the degeneration of muscle end plates. A clinical diagnosis based on clinical examinations supported by radiological and electrophysiological investigations is required that guides the specific procedures to be chosen. The surgeons must prioritize the objectives of reconstruction and keeping the different lifeboats for the use in future before choosing a specific nerve transfer. Also, it is important to be familiar with different nerve transfers so that one can select and perform a specific one based on pre-operative examinations and intraoperative findings of nerve stimulations. The author aims to describe the approach for exploring and dissecting the brachial plexus and different surgical techniques of nerve transfers used for different muscle reinnervation...
Motor nerve transfers for restoration of upper arm function in adult brachial plexus injuries
2022
Introduction: Nerve transfers are the only surgical option for reconstruction of directly irreparable injuries of the brachial plexus. In the recent years, there has been a trend toward the increased use of nerve transfers, with the introduction of new methods and novel indications. Patients with total brachial plexus palsy generally have poor outcomes due to the limited number of donor nerves. On the contrary, patients with partial injuries involving the C5, C6, and sometimes C7 spinal nerves have favorable outcomes in a large majority of cases. In both situations, restoration of elbow flexion and shoulder functions are the main priorities. The purpose of this review article to characterize the advantages, problems and controversies of nerve transfers. Methods: PubMed/Medline database was searched for English-language original research and series of adult patients who received nerve transfers for functional restoration of the upper arm, performed within one year after injury and with minimum follow-up of one year. Literature search for outcome analysis was limited to articles published after 1990, amounting to 45 systematic reviews / meta-analyses of the most common nerve transfers (intercostal, spinal accessory, fascicular, and collateral branches of the brachial plexus). Analysis of clinical outcomes was based on Medical Research Council (MRC) grading system for muscle strength, and grades M3 or more were considered as useful functional recovery. Results: A total of 70 articles were included. Generally, intraplexal nerve transfers resulted in a higher rate and better quality of recovery compared to extraspinal transfers. Grades M3 or higher were obtained in 72% of the intercostal and 73% of the spinal accessory nerve transfers for restoration of elbow flexion, and in 56% vs. 98% of transfers for restoration of shoulder function. Among intraplexal nerve transfers, elbow flexion was restored in 84% to 91% of the medial pectoral, 100% of the thoracodorsal, and 94% to 100% of the single or double fascicular nerve transfers. Shoulder function was restored in 81,8% of the medial pectoral, 86% to 93% of the thoracodorsal, and 100% of the triceps branch nerve transfers. Dual nerve transfer (simultaneous reinnervation of the suprascapular and axillary nerves), resulted in 100% rate of recovery. Conclusion: Double fascicular transfer for restoration of elbow flexion and dual nerve transfer for restoration of shoulder function resulted in the most favorable results relative to other transfers, especially regarding quality of recovery. Medial pectoral and thoracodorsal nerve transfers were reasonable alternatives for restoration of both functions.
Nerve transfers in children with traumatic partial brachial plexus injuries
Microsurgery, 2008
Brachial plexus trauma is a rare condition in children except for obstetrical lesions, for which nerve grafting is generally proposed. Two children (9 and 12 years old) with C5 and C6 traumatic brachial plexus avulsion lesions are presented, where elbow flexion and shoulder abduction and external rotation were the functions to be restored. Nerve transfers have been performed. Shoulder abduction was restored by an accessory-to-suprascapular nerve transfer in one patient, while the triceps long head motor branch was transferred to the axillary nerve in both patients. Fascicles of the ulnar and median nerve were transferred respectively to the biceps muscle nerve and the brachialis motor branch. At 11 months follow-up, the elbow flexion scored M4 and the shoulder abduction recovered in both patients. No complications were observed. Nerve transfers currently used in adult patients may be applied in children with traumatic partial brachial plexus palsies.
Indian Journal of Plastic Surgery
Introduction Posttraumatic brachial plexus injuries are devastating, as the brain and spinal cord are disconnected from the upper limb. Restoration of elbow flexion has been widely recognized as the primary objective of nerve reconstruction. In the absence of utilizable (ruptured) root stumps in the neck, one has recourse only to nerve transfers. The direct transfer of intercostal nerves to the musculocutaneous nerve is one of the techniques that has been commonly employed over the past four decades. However, the outcomes of this procedure cited in the literature have varied considerably. The patient’s age and the delay from the accident to surgery have been known to affect the results of nerve reconstruction operations. The authors present a study of the effect of these parameters on intercostal nerve transfers. Methods The data of 232 patients with total and near-total brachial plexus injuries treated by the senior author between April 1995 and December 2015 was examined. Intercos...
Nerve Root Grafting and Distal Nerve Transfers for C5-C6 Brachial Plexus Injuries
The Journal of Hand Surgery, 2010
Purpose To investigate the results of distal nerve transfer, with and without nerve root grafting, in C5-C6 palsy of the brachial plexus. Methods We prospectively studied 37 young adults with C5-C6 brachial plexus palsy who underwent surgical repair an average of 6.3 months after trauma. In 7 patients, no nerve roots were available for grafting, so reconstruction was achieved by transferring the accessory nerve to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps branches to the axillary nerve (a triple nerve transfer). In 24 patients, C5 nerve root grafting to the anterior division of the upper trunk was combined with triple nerve transfer. In 6 patients, the C5ϩC6 nerve roots were grafted to the anterior and posterior divisions of the upper trunk, the accessory nerve was transferred to the suprascapular nerve, and ulnar nerve fascicles were connected to the biceps motor branch. The range of shoulder abduction/ external rotation recovery and elbow flexion strength were evaluated between 24 and 26 months after surgery. Results Both full abduction and full external rotation of the shoulder were restored in one of the 7 patients in the C5 and C6 nerve root avulsion group, in 14 of 21 patients who received C5 nerve root grafting, and in 2 of 6 patients in the C5ϩC6 nerve root graft group. The average percentages of elbow flexion strength recovery, relative to the normal, contralateral side, were 27%, 43%, and 59% for the C5-C6 nerve root avulsion, C5 nerve root graft, and C5ϩC6 nerve root graft groups, respectively. Conclusions We repaired C5-C6 brachial plexus palsies using a combination of strategies depending on the site of root injury (ie, intradural vs extradural). Patients with injuries that were able to be reconstructed with both root grafting and nerve transfers had the best function. These results suggest that the combined use of nerve transfers and root grafting may enhance outcomes in the reconstruction of C5-C6 injuries of the brachial plexus.
Arquivos de neuro-psiquiatria, 2017
Restoration of the sensitivity to sensory stimuli in complete brachial plexus injury is very important. The objective of our study was to evaluate sensory recovery in brachial plexus surgery using the intercostobrachial nerve (ICBN) as the donor. Eleven patients underwent sensory reconstruction using the ICBN as a donor to the lateral cord contribution to the median nerve, with a mean follow-up period of 41 months. A protocol evaluation was performed. Four patients perceived the 1-green filament. The 2-blue, 3-purple and 4-red filaments were perceptible in one, two and three patients, respectively. According to Highet's scale, sensation recovered to S3 in two patients, to S2+ in two patients, to S2 in six patients, and S0 in one patient. The procedure using the ICBN as a sensory donor restores good intensity of sensation and shows good results in location of perception in patients with complete brachial plexus avulsion.
Microsurgery, 2019
Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury. Methods: PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed. Results: In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022). Conclusions: Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery.
Arquivos de neuro-psiquiatria, 2017
Few donors are available for restoration of sensibility in patients with complete brachial plexus injuries. The objective of our study was to evaluate the anatomical feasibility of using the intercostobrachial nerve (ICBN) as an axon donor to the lateral cord contribution to the median nerve (LCMN). Thirty cadavers were dissected. Data of the ICBN and the LCMN were collected, including diameters, branches and distances. The diameters of the ICBN and the LCMN at their point of coaptation were 2.7mm and 3.7mm, respectively. The ICBN originated as a single trunk in 93.3% of the specimens and bifurcated in 73.3%. The distance between the ICBN origin and its point of coaptation to the LCMN was 54mm. All ICBNs had enough extension to reach the LCMN. Transfer of the ICBN to the LCMN is anatomically feasible and may be useful for restoring sensation in patients with complete brachial plexus injuries.