Reconstruction of Complete Palsies of the Adult Brachial Plexus by Root Grafting Using Long Grafts and Nerve Transfers to Target Nerves (original) (raw)
Related papers
2007
Restoration of elbow flexion is the first goal in brachial plexus injuries. The current procedures using nerve grafts and nerve transfers authorize more extensive repairs, with different possible targets: shoulder, elbow extension, and hand. Elbow extension is important to stabilize the elbow without the contralateral hand and allows achieving a useful grasp. The transfer of the intercostal nerves to the nerve of the long head of the triceps may restore this function in brachial plexus palsies. Furthermore, in case of C5 to C7 palsy, this transfer spares the radial nerve and gives a chance to spontaneous triceps recovery by the reinnervation from C8 root. Moreover, in case of absence or insufficient (M0 to M2 according to Medical Research Council scoring) recovery of elbow flexion strength by nerve surgery, the reinnervated triceps can be transferred. We present the technique of intercostal nerve transfer to the long head of the triceps branch to restore elbow extension in brachial plexus palsy. Results concerning 10 patients are presented.
Injury, 2019
Elbow flexion is the first goal in upper partial brachial plexus palsy treatment. However, elbow extension is essential for daily living activities. To recover this function, one fascicle of ulnar nerve can be transferred to the branch of the long head of the triceps, but this procedure has been previously published in only two patients. The goal of our study is to assess a larger series of transfers of one fascicle of ulnar nerve to the branch of the long head of the triceps to help patients recover elbow extension. Ten male patients with C5, C6 and C7 brachial plexus injuries underwent operation. For shoulder recovery, we transferred the spinal accessory nerve and rhomboid nerve. For elbow flexion, one fascicle of median nerve was transferred to the nerve of the biceps. For elbow extension, we transferred one fascicle of ulnar nerve to the branch of the long head of the triceps. Tendon transfers were performed for wrist and finger extension. Nine patients recovered M4 elbow flexion and extension. One patient had M3 elbow extension and flexion. Average active shoulder elevation was 85 °and average active shoulder external rotation was 65 °All patients recovered finger and wrist extension. The classical techniques of grafts or phrenic or intercostal nerve transfers to recover elbow extension are not always reliable, according to the literature. Because the harvested ulnar nerve motor fascicle is close to the branch of the long head of the triceps, the recovery time for this procedure is shorter than that of other described nerve transfers. The isolated recovery of the reinnervated long head of the triceps muscle excludes spontaneous recovery occasionally noted in upper root plexus injuries. The transfer of one fascicle of ulnar nerve to the branch of the long head of the triceps is reliable for active elbow extension recovery in C5, C6 and C7 brachial plexus palsies.
Reanimation of elbow extension with intercostal nerves transfers in total brachial plexus palsies
Microsurgery, 2010
Background: Restoration of flexion in the elbow is the priority in the management of brachial plexus injuries. Current techniques of reconstructions, combining both nerve grafting and nerve transfer, allow more extensive repair, with additional targets: shoulder, elbow extension, hand. The transfer of intercostal nerves onto the nerve of the triceps long head is used to restore elbow extension. The aim of this retrospective study is to evaluate the results of this procedure, in total brachial plexus palsies with uninjured C5 and C6 roots. Methods: Eleven patients with total brachial plexus injury were reviewed 24 months in average after intercostal nerves transfer. The average age of the patients was twenty-nine years. The average time to surgery after occurrence of the injury was 5 months. Triceps re-innervation and strength of elbow extension were evaluated. Results: The averaged time required for triceps re-innervation after intercostal nerve transfer was 9 months. Seven patients achieved M4 elbow extension according to the Medical Research Council grading system. Two patients achieved M3 elbow extension. Two patients had poor results (M2 and M0). Discussion and conclusions: Transfer of intercostal nerves onto the nerve of the triceps long head is a reliable procedure for the restoration of elbow extension in total brachial plexus palsy.
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.
Nerve reconstruction: A cohort study of 93 cases of global brachial plexus palsy
Indian Journal of Orthopaedics, 2011
Introduction: Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers. Materials and Methods: Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients). Results: Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft). Conclusion: Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.
Nerve Transfer to the Triceps After Brachial Plexus Injury: Report of Four Cases
The Journal of Hand Surgery, 2011
These case reports review the clinical outcomes of 4 patients who underwent nerve transfer to a triceps motor branch of the radial nerve. Mean follow-up was 26 Ϯ 15 months. Two patients had a transfer using an ulnar nerve fascicle to the flexor carpi ulnaris muscle, yielding a motor recovery of grade M5 elbow extension strength in one case and M4ϩ in the other. In 1 patient, a thoracodorsal nerve branch was used as the donor; this patient recovered M4 strength. One patient had a transfer using a radial nerve fascicle to the extensor carpi radialis longus muscle and recovered M5 strength. These outcomes indicate that expendable fascicles of the ulnar, thoracodorsal, and radial nerves are viable donors in the surgical reconstruction of elbow extension.
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 for Restoring Elbow Flexion in Brachial Plexus Palsy
Brachial Plexus Injury [Working Title], 2021
Nerve transfers (NT) consist in sectioning a donor nerve and connecting it to the distal stump of a recipient unrepairable nerve. For elbow flexion restoration in brachial plexus palsy (BPP) we used different NT: 1) GF motor Ulnar Nerve to Biceps nerve (Oberlin technique), 2) Double fascicular median/ulnar to biceps/brachialis nerve transfer (Mackinnon), 3) InterCostal Nerves (ICN) to MCN (+/− nerve graft), 4) Medial Pectoral Nerve (MPN) to MCN, 5) ThoracoDorsal Nerve (TDN) to MCN, 6) Spinal Accessory Nerve (SAN) to MCN transfer, 7) Phrenic Nerve (PhN) to MCN, 8) Cervical Plexus C3-C4 to MCN and 9) Contralateral C7 (CC7). I want to present my personal experience using the phrenic nerve (PhN), the intercostal nerves (ICN) and Oberlin’s technique. The aim of this retrospective study is to evaluate the results of this procedure in BPP. NT is an important goal in BPP. ICN transfer into the nerve of biceps for elbow flexion recovery is a reliable procedure in BPP. ICN transfer for tricep...
Journal of Neurosurgery, 2021
OBJECTIVENerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series.METHODSSupra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength.RESU...
Transfer of the Accessory Nerve to the Suprascapular Nerve in Brachial Plexus Reconstruction
The Journal of Hand Surgery, 2007
Purpose: Transfer of the accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with brachial plexus palsy. We propose dissecting both nerves via a distal oblique supraclavicular incision, which can be prolonged up to the scapular notch. The results of the transfer to the suprascapular nerve are compared with those of the combined repair of the suprascapular and axillary nerves. Methods: Thirty men between the ages of 18 and 37 years with brachial plexus trauma had reparative surgery within 3 to 10 months of their injuries. In partial injuries with a normal triceps, a triceps motor branch transfer to the axillary nerve was performed. The suprascapular and accessory nerves were dissected via an oblique incision, extending from the point at which the plexus crosses the clavicle to the anterior border of the trapezius muscle. In 10 patients with fractures or dislocations of the clavicle, the trapezius muscle was partially elevated to expose the suprascapular nerve at the suprascapular notch. Results: In all cases, transfer of the accessory to the suprascapular nerve was performed without the need for nerve grafts. A double lesion of the suprascapular nerve was identified in 1 patient with clavicular dislocation. In those with total palsy, the average improvement in range of abduction was 45°, but none of the patients with total palsy recovered any active external rotation. Patients with upper-type injury recovered an average of 105°of abduction and external rotation. If only patients with C5-C6 injuries were considered, the range of abduction and external rotation increased to 122°and 118°, respectively. Conclusions: Use of the accessory nerve for transfer to the suprascapular nerve ensured adequate return of shoulder function, especially when combined with a triceps motor branch transfer to the axillary nerve. The supraclavicular exposure proposed here for the suprascapular and accessory nerves is advantageous and can be extended easily to explore the suprascapular nerve at the scapular notch. (J Hand Surg 2007;32A:989 -998.