Comparison of Surgical Strategies between Proximal Nerve Graft and/or Nerve Transfer and Distal Nerve Transfer Based on Functional Restoration of Elbow Flexion: A Retrospective Review of 147 Patients (original) (raw)
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Nerve Transfers for Restoration of Elbow Flexion following Adult Brachial Plexus Injury
2017
Restoration of elbow flexion is a fundamental functional requirement following adult brachial plexus injury. Nerve transfer offers advantages over grafting and has shown better motor recovery. Contemporary literature regarding elbow flexion reconstruction is reviewed and compared. Intraplexal expendable nerve donors for C5, C6, C7 injuries allow nerve regeneration closer to the end organ and hence improved outcomes. A strategic approach using intraplexal donors for elbow restoration allows reservation of extraplexal donors for transfer to reconstruct shoulder function.
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.
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.
The Journal of Hand Surgery, 2011
Purpose Restoration of elbow flexion is an important goal in brachial plexus injuries. Double nerve transfers using fascicles from ulnar and median nerves have consistently produced good results without causing functional compromise to the donor nerve. According to conventional practice, these double nerve transfers are dependent on the careful isolation of ulnar and median nerve fascicles, which are responsible for wrist flexion, using a handheld nerve stimulator. Here we suggest that fascicular selection by nerve stimulation might not be a necessity when executing double nerve transfers for restoration of elbow flexion in brachial plexus injuries. Methods This is a retrospective case control study in 26 patients with C5, C6 brachial plexus injuries that were managed with double nerve transfers between March 2005 and January 2008. Our technique consisted of transferring 2 fascicles, one each from the ulnar and the median nerve, directly onto the biceps and brachialis motor branches. Contrary to the standard practice, the ulnar or median nerve fascicles were selected without using a handheld nerve stimulator. Results were compared to 21 cases (control group) in which a nerve stimulator was used for fascicular selection. The denervation period ranged from 3 to 9 months. Results Twenty-four patients of the study group experienced full restoration of elbow flexion, and 2 had an antigravity flexion of 120°and 110°. The EMG revealed the first sign of reinnervation of biceps and brachialis muscle at 9 Ϯ 2 weeks and 11 Ϯ 2 weeks, as compared to 9 Ϯ 2 weeks and 12 Ϯ 4 weeks in the control group. After surgery, the appearance of initial evidence of elbow flexion, the range and mean of elbow flexion strength, and the difference between preoperative and postoperative grip and pinch strengths were comparable in both groups. At 24 to 28 months follow-up, 19 patients of the study group had M4 power and 7 had M3, compared to 18 and 3 cases, respectively, in the control group. The P values for Medical Research Council grade, strength of elbow flexion, and range of elbow flexion between the 2 groups did not reveal any significant statistical difference. Conclusions Double nerve transfer is a reliable technique for restoring elbow flexion in brachial plexus injuries. There is no advantage of using a nerve stimulator in selecting fascicles before performing the nerve transfer.
Microsurgery, 2019
Objectives: Double fascicular transfer is argued to result in improved elbow flexion compared to the traditional ulnar fascicular transfer because it reinnervates both the biceps and the brachialis. This study seeks to determine if double fascicular transfer should be preferred over ulnar fascicular transfer to restore elbow flexion in patients with upper trunk brachial plexus injuries (BPI) by analyzing the current database of literature on the topic. Methods: A systematic review was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting Medical Research Council (MRC) scores on individual patients undergoing ulnar fascicular transfer and double fascicular transfer (ulnar and median nerve fascicle donors). Patients were excluded if: age < 18 years old and follow-up <12 months. Demographics obtained include age, sex, extent of injury (C5-C6/C5-C7), preoperative interval, procedure type, and follow-up time. Outcomes included absolute MRC score and ability to achieve MRC score ≥3 and ≥4. Univariate and multivariate regression analyses were completed to evaluate predictors of postoperative outcomes. Results: Eighteen studies (176 patients) were included for pooled analysis. Patients that underwent double fascicular transfer had a higher percentage of patients attain a MRC score ≥ 4 compared to ulnar fascicular transfer subjects (83.0% vs. 63.3%, p = .013). Double fascicular transfer was a predictor of achieving high MRC scores (OR = 2.829, p = .015). Multivariate analysis showed that procedure type was the only near significant predictor of ability to obtain MRC ≥4 (OR: 2.338, p = .054). Conclusions: This analysis demonstrates that double fascicular transfer is associated with superior postoperative outcomes and should be performed for restoring elbow flexion. 1 | INTRODUCTION Brachial plexus injury (BPI) commonly occurs in the young, predominantly male population and can result in loss of elbow and/or shoulder function, which can significantly impact quality of life (Verdins & Kapickis, 2018). To lessen the burden of disability, several reconstructive options exist to restore function in these patients; in particular, loss of elbow flexion can be managed with nerve transfer. First described by Oberlin et al. in 1994 (Ray, Pet, Yee, & Mackinnon, 2011), this procedure requires the neurotization of an expendable fascicle of the ulnar
Neurosurgery, 2019
INTRODUCTION Restoration of elbow flexion is the priority in traumatic brachial plexus injuries. Surgical approaches commonly include nerve transfers and nerve grafting. Our objective was to evaluate the safety and efficacy profile of nerve transfers vs grafting for traumatic nonobstetric brachial plexus injuries. METHODS This systematic literature review was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed until November 2018. A random-effects model meta-analysis was conducted, and the I-square was used to assess heterogeneity. The Medical Research Scale (MRC) score was used to assess the efficacy of the procedures. RESULTS A total of 9 studies comprising 490 patients overall were identified. In the pooled analysis, functional recovery of elbow flexion defined as MRC = M3, was superior in the transfer (N = 272/350, 77.7%) compared to the graft group (N = 99/140, 70.7%); however statistical significance was not reached (OR: 1....
Nerve grafting vs. common infraclavicular intraplexal nerve transfer in elbow flexion restoration
Turkish Neurosurgery
been increasing (37). Supraclavicular traction injuries occur in 75% of the patients with brachial plexus injury (11,35). Around 55% of the supraclavicular injuries involve all five roots, resulting in a flail limb (total brachial plexus paralysis) (35). About 45% of upper brachial plexus injuries in adults involve the C5-C6 and/or C7 roots (35). Upper brachial plexus █ INTRODUCTION T raumatic brachial plexus injuries can have tremendous effects on function of the upper extremity (2,11,19). In recent years, with the development of high-speed vehicles and motor sports, the frequency of these injuries has AIM: To compare the results of nerve grafting versus common infraclavicular intraplexal nerve transfer in elbow flexion restoration. MATERIAL and METHODS: The study included 39 patients with upper brachial plexus palsy who were operated using common intraplexal nerve transfer (Oberlin procedure) and the thoracodorsal and medial pectoral nerve transfer to the musculocutaneous nerve or grafting of C5 to the musculocutaneous nerve, for elbow flexion restoration. All patients underwent detailed preoperative evaluation, which included clinical and neurological examinations, electrophysiological investigation and neuroradiological studies. The final evaluation of achieved recovery of elbow flexion was done two years after surgery, using the British Medical Council scale. RESULTS: We achieved functional satisfactory recovery (M3, M4, M5) in 29 of 30 patients (96.7%) in the common intraplexal nerve transfer group, and in 4 of 9 patients in the nerve grafting group (44.4.%). There was a significant statistical difference between these two groups in favor of common intraplexal nerve transfers over C5 grafting to the musculocutaneous nerve regarding functional recovery. CONCLUSION: The results of our study concur with the findings of previous studies favoring intraplexal nerve transfers over nerve grafting in the restoration of elbow flexion in upper brachial plexus palsy. They reveal that intraplexal nerve transfers are clearly the primary treatment modality in cases of upper brachial plexus palsy without any sign of viable proximal C5 stump presence, while in cases of upper brachial plexus palsy with signs of viable proximal C5 stump the choice of the best treatment modality is still controversial.
Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery
Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, ± C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n = 43), or a fascicle of the median nerve (group B, n = 16) or a combination of both (group C, n = 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar + median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). T...
Journal of Neurosurgery, 2013
Object Recent advancements in operative treatment of the brachial plexus authorized more extensive repairs and, currently, elbow extension can be included in the rank of desirable functions to be restored. This study aims to describe the author's experience in using the medial pectoral nerve for reinnervation of the triceps brachii in patients sustaining C5–7 palsies of the brachial plexus. Methods This is a retrospective study of the outcomes regarding recovery of elbow extension in 12 patients who underwent transfer of the medial pectoral nerve to the radial nerve or to the branch of the long head of the triceps. Results The radial nerve was targeted in 3 patients, and the branch to the long head of the triceps was targeted in 9. Grafts were used in 6 patients. Outcomes assessed as Medical Research Council Grades M4 and M3 for elbow extension were noted in 7 (58%) and 5 (42%) patients, respectively. Conclusions The medial pectoral nerve is a reliable donor for elbow extension ...