Phrenic nerve transfer for brachial plexus motor neurotization

We report a series of 164 patients who underwent phrenic neurotization to elements of the brachial plexus with root avulsion injuries. Recipient nerves included musculocutaneous nerve in 125 patients (78 direct neurotizations and 48 with intervening autograft), median nerve in 10 patients, and a variety of other nerves in 28 patients. Sixty-five patients presented a follow-up period of 2 or more years. Of this group, 55 patients (84.6%) achieved a recovery of M-3 or better. We observed no long-term deleterious effects on respiratory function.     

Extraplexual neurotization of brachial plexus

The authors reviewed 62 neurotizations of the brachial plexus in 71 patients performed between 1974 and 1989. The nerves used were the accessory, the motor or sensory branches of the cervical plexus, and the intercostals. Twenty-five suprascapular nerves, 19 musculocutaneous, 4 medial roots of the median nerve, and 12 lateral roots of the median nerve were neurotized. The authors concluded that useful results can be achieved using extraplexual neurotizations. © 1994 Wiley-Liss, Inc.     

Accessory nerve neurotization in infants with brachial plexus birth palsy

We report the surgical results of 13 accessory nerve neurotizations in brachial plexus birth palsy. The mean age at operation was 5.9 months. The accessory nerve was transferred to three C5 roots, to three C6 roots, to four posterior division of the middle trunks, to one musculocutaneous nerve, and to two suprascapular nerves. Sixty-seven percent of the cases acquired M4 or more in the deltoid muscle, 88% in the infraspinatus muscle, and 100% in the biceps brachii muscle. Twenty-five percent of the cases acquired M4 or more in the triceps brachii muscle and the wrist extensor muscles. These results were much better than formerly reported for adult cases by other authors. No functional compromise of the trapezius muscle was noted. The accessory nerve neurotization can be used safely and effectively in neurosurgical reconstruction of the brachial plexus palsy in infants. © 1994 Wiley-Liss, Inc.     

Transfer of the accessory nerve to the suprascapular nerve in brachial plexus reconstruction

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 degrees , but none of the patients with total palsy recovered any active external rotation. Patients with upper-type injury recovered an average of 105 degrees of abduction and external rotation. If only patients with C5-C6 injuries were considered, the range of abduction and external rotation increased to 122 degrees and 118 degrees , 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.     

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

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

Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury

In the management of upper type of brachial plexus injury, reconstruction to restore shoulder function is accomplished by multiple nerve transfers. We used the accessory nerve to neurotize the suprascapular nerve in 12 patients (11 men, 1 woman) from 1989 to 2003. The average age at the time of operation was 28.1 years (range 16 to 53). The mean preoperative time was 3.6 months. The type of paralysis was C5-C6 type in four cases, C5-C7 type in five cases, and C5-C8 type in three cases. The average time of follow-up was 28.5 months. All the patients showed reinnervation of the supraspinatus and infraspinatus muscles that was confirmed by electromyogram. At the time of final followup, the average shoulder flexion was 70.4 degrees and abduction was 77.1 degrees. However, average shoulder external rotation was only 16.7 degrees. We compared the shoulder flexion and abduction in patients with or without paralysis of the serratus anterior muscle and found significantly better functional outcome in the latter group of patients. We, therefore, conclude that repair of long thoracic nerve is mandatory for achieving optimum shoulder function.     

Repair of severe traction lesions of the brachial plexus

Since 1972, the author has performed 259 brachial plexus repairs and various associated secondary procedures. The best results were obtained with surgery delayed four to five weeks, because the preoperative assessment of the lesion is more accurate after wallerian degeneration has occurred. In addition, formation of a proximal neuroma allows definition of the exact limits for resection. In cases with associated vascular damage, the vessels should be repaired at the same time as the nerve grafts unless there is severe ischemia. Intraspinal exploration with cervical laminectomy is not justified because intraspinal avulsion is always due to rootlet avulsion. Division of the clavicle to facilitate exploration of the anatomy of the plexus where it is the most complex is advocated. In general, distal grafting allows the recovery of a single function, which is preferable to an attempt at total anatomic repair. The adverse effects of contractions must be avoided. The priority of restoration of functions is an important consideration. Elbow flexion should be the first priority, followed by wrist extension, finger flexion, and shoulder abduction, in that order. The results of grafting may be improved by ancillary operations such as shoulder fusion, flexor tendon tenodesis, humeral derotation, and other procedures that provide limited function for patients with various incomplete and complete avulsions. Microsurgical repairs of brachial plexus lesions currently offer the best results for patients with this type of injury.     

Nerve transfer in brachial plexus traction injuries.

Brachial plexus palsy due to traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Nerve transfer is the only possibility for repair in cases of spinal nerve-root avulsion. This technique was analyzed in 37 patients with 64 reinnervation procedures of the musculocutaneous and/or axillary nerve using upper intercostal, spinal accessory, and regional nerves as donors. The most favorable results, with an 83.8% overall rate of useful functional recovery, were obtained in patients with upper brachial plexus palsy in which regional donor nerves, such as the medial pectoral, thoracodorsal, long thoracic, and subscapular nerves, had been used. The overall rates of recovery for the spinal accessory and upper intercostal nerves were 64.3% and 55.5%, respectively, which are significantly lower. The authors evaluate the results of nerve transfer and analyze different donor nerves as factors influencing the prognosis of surgical repair.     

An experimental study of the treatment of root avulsion of brachial plexus using contralateral C7 nerve neurotization (nerve transfer)]

This study compared the functional results of contralateral C7 root neurotization with homolateral phrenic nerve transfer for repairing root avulsion of brachial plexus in rats. It was found that in the C7 nerve root group all the parameters of evoked muscle potential amplitude (EMPA), regenerating axon count, biceps weight and muscle fibre area, and muscular maximal tetanus tension were statistically superior (P < 0.05-0.01) to those in the phrenic nerve group; while there were no significant differences between these two groups in motor nerve latency regenerating axon area and persisting time of muscular maximal tetanus tension (P > 0.05). The reasons why C7 root neurotization is superior to phrenic nerve transfer were also discussed.     

Contemporary treatment of peripheral nerve and brachial plexus lesions

Summary The paper outlines modern microsurgical techniques utilized in the repair of injured peripheral motor and sensory neurons. The diagnostic evaluation and its timing, which depend on the level and the extent of the lesion, are proposed. The author stresses the need during the operation for close monitoring, which is a prerequisite of proper coaptation of the severed nerve structures. A technically perfect microsurgical repair provides optimal conditions for regeneration of the divided peripheral nerves and/or brachial plexus. The repair of avulsion injuries of the brachial plexus still poses many technical problems; the author proposes the use of intercostal nerves as new sources for grafts. Pain, which is one of the major problems occurring with peripheral nerve injuries, especially with lesions to the brachial plexus, is not dealt with in detail. The author maintains that the contemporary treatment of peripheral nerve injuries as a rule yields good results, while this is not yet true of the management of brachial plexus lesions.     

Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries

Combined neurotization of both axillary and suprascapular nerves in shoulder reanimation has been widely accepted in brachial plexus injuries, and the functional outcome is much superior to single nerve transfer. This study describes the surgical anatomy for axillary nerve relative to the available donor nerves and emphasize the salient technical aspects of anterior deltopectoral approach in brachial plexus injuries. Fifteen patients with brachial plexus injury who had axillary nerve neurotizations were evaluated. Five patients had complete avulsion, 9 patients had C5, six patients had brachial plexus injury pattern, and one patient had combined axillary and suprascapular nerve injury. The long head of triceps branch was the donor in C5,6 injuries; nerve to brachialis in combined nerve injury and intercostals for C5‐T1 avulsion injuries. All these donors were identified through the anterior approach, and the nerve transfer was done. The recovery of deltoid was found excellent (M5) in C5,6 brachial plexus injuries with an average of 134.4° abduction at follow up of average 34.6 months. The shoulder recovery was good with 130° abduction in a case of combined axillary and suprascapular nerve injury. The deltoid recovery was good (M3) in C5‐T1 avulsion injuries patients with an average of 64° shoulder abduction at follow up of 35 months. We believe that anterior approach is simple and easy for all axillary nerve transfers in brachial plexus injuries. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Rehabilitation of patients following traction lesions of the brachial plexus

The management of patients with brachial plexus lesions requires a multidisciplinary approach. We insist on admission to our rehabilitation ward for a full assessment by the physiotherapist, occupational therapist, rehabilitation officer, and social worker when necessary. We confirm the diagnosis by clinical, electrophysiologic, and radiologic techniques and set out a plan of action, either involving definitive surgery or a conservative program involving functional splintage, relief of pain when possible, and return to work. We insist on regular follow-ups to check that the pain is still being relieved. At subsequent reviews it may become clear that spontaneous recovery is not going to occur, and a program of reconstructive surgery can be instituted. In general terms, three years or more should have elapsed before accepting that elbow flexion is not going to return. In patients with C5-C6 lesions, where elbow flexion is permanently paralyzed, the simple elbow lock splint may be perfectly satisfactory, but in some patients it may be wise to advise reconstructive procedure. In our experience the most satisfactory means of restoring elbow flexion is the Steindler flexor plasty, advancing the origins of the extensors and flexors of the forearm up the humerus. If present, latissimus dorsi can be transferred to replace the biceps. The pectoralis major transfer is useful but almost always requires an external rotation osteotomy, as there is too much adduction when the patient flexes the elbow. Finally, triceps can be transferred to biceps, but this is an operation that we do not like, as elbow extension is so useful.(ABSTRACT TRUNCATED AT 250 WORDS)