Transfer of the medial pectoral nerve: myth or reality?

OBJECTIVE: Transfer of the medial pectoral nerve is one of the most controversial procedures used to reinnervate the paralyzed upper arm because of brachial plexus spinal nerve root avulsion or directly irreparable proximal lesions of spinal nerves. The purpose of this study was to determine the value of this type of nerve transfer to the musculocutaneous and axillary nerves. METHODS: The 25 patients included in the study comprised 14 patients who had nerve transfer to the musculocutaneous nerve and 11 who underwent nerve transfer to the axillary nerve. These patients' functional recovery and the time course of their recovery were analyzed according to the type of transfer of one donor nerve or the donor nerve in combination with other donors. RESULTS: Useful functional recovery was achieved in 85.7% of patients who had nerve transfer to the musculocutaneous nerve and in 81.8% of patients who underwent nerve transfer to the axillary nerve. There was no significant difference in results with regard to the type of nerve transfer and which recipient nerves were involved. A strong trend toward better results after procedures involving the use of a donor nerve combined with other donors was observed, however. CONCLUSION: Our surgical results suggest that the transfer of the medial pectoral nerve to the musculocutaneous nerve and also to the axillary nerve may be a reliable and effective procedure.     

Surgical outcomes following nerve transfers in upper brachial plexus injuries

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).     

肌电图-神经电图测定健侧颈_7神经根移位桥接至受体神经后再生的临床研究

目的　用肌电图 -神经电图检测方法 ,研究健侧颈 7神经根移位通过桥接至受体神经后再生的状况。方法　 1996年 3月至 1998年 9月 ,对 2 8例健侧颈 7移位二期手术后患者 ,定期进行肌电图 -神经电图随访。术后随访时间为 3～ 5 8个月 ,平均 15 .4个月。分别在胸锁关节、胸腋部、腋部、肘部或外侧肌间隔刺激受体神经 (肌皮神经、桡神经和正中神经 ) ,于该神经支配的相应肌肉上记录复合肌肉动作电位 (CMAP) ,测定其潜伏期 (L at)、波幅 (Amp)。计算出动力神经纤维在受体神经的运动传导速度(MNCV) ,并观察其肌电图表现。结果　患侧桡、肌皮和正中神经支配的相应肌肉 ,分别在术后 4、6和 12个月时检测到神经再生电位。结论　健侧颈7神经根移位后 ,受体神经中出现再生电位最早的为肌皮神经 ,桡神经次之 ,正中神经最晚     

Effect of ipsilateral C7 nerve root transfer on restoration of rat upper trunk muscle and nerve function after brachial plexus root avulsion

The effects of ipsilateral cervical nerve root transfer on the restoration of the rat upper trunk muscle and nerve brachial plexus root avulsion were studied. After simulated root avulsion of the upper trunk brachial plexus, 120 rats were randomly divided into 4 groups: (A) ipsilateral C7 root transfer group; (B) Oberlin group; (C) phrenic nerve group; and (D) no axillary nerve restoration group. At 3, 6, and 12 weeks postoperatively, Ochiai score, Barth feet overreaching test, Terzis grooming test, and indices of neurotization were determined in 10 rats from each group. Twelve weeks postoperatively, nearly all the behavioral, neuroelectrophysiological, and histological outcomes of the axillary nerve and deltoid muscle and some of the indices of musculocutaneous nerve and biceps brachii function in the ipsilateral C7 group were superior to those in the other 3 groups. No significant difference was found between the ipsilateral C7 group and the other 3 groups in recovery rate of wet biceps muscle weight. No significant difference was found between the ipsilateral C7 group and the Oberlin group in the recovery of the axillary nerve compound muscle action potential and biceps brachii cell size. No significant difference was found between the ipsilateral C7 group and the phrenic nerve and no axillary nerve restoration groups in amplitude recovery rate of musculocutaneous nerve compound muscle action potential. No significant difference was found between the ipsilateral C7 and the Oberlin groups in the early recovery of musculocutaneous nerve compound muscle action potential, but recovery was significantly better in the ipsilateral C7 group at 12 weeks. Ipsilateral C7 root transfer can improve the quality of restoration of muscle and nerve function in the rat upper trunk after brachial plexus root avulsion.     

Paralytic shoulder secondary to post-traumatic peripheral nerve lesions in the adult

A critical review is presented of the indications for nerve repair or transfer and for palliative operations in the management of paralytic shoulder following traumatic neurological injuries in the adult. Different situations are considered: paralytic shoulder following supraclavicular lesions of the brachial plexus, following retro- and infraclavicular lesions and following lesions to the terminal branches of the plexus (axillary, suprascapular and musculocutaneous nerves) and finally problems related to lesions of the accessory nerve and the long thoracic nerve. I. Supraclavicular lesions of the brachial plexus. In complete (C5 to T1) lesions, the possibilities for nerve repair or transfer are at best limited, and the aim is to restore active flexion of the elbow. Palliative operations may be associated in order to stabilize the shoulder. In case of a complete C5 to T1 root avulsion, amputation at the distal humerus may be considered but is rarely performed combined with shoulder arthrodesis if the trapezius and serratus anterior muscles are functioning. The shoulder may also be stabilized by a ligament plasty using the coracoacromial ligament. In cases where the supraspinatus and long head of the biceps have recovered, but where active external rotation is absent, function may be improved by derotation osteotomy of the humerus. In partial C5,6 or C5,6,7 lesions, the indications for nerve repair and transfer are wider, as well as the indications for muscle transfers. In C5,6 lesions, a neurotization from the accessory nerve to the suprascapular nerve gives 60% satisfactory results; this is also true following treatment of C5,6,7 lesions, whereas restoration of active elbow flexion is obtained in 100% of cases in C5,6 lesions but only in 86% in C5,6,7 lesions. In cases where shoulder function has not been restored, palliative operations may be considered: arthrodesis or, more often, derotation osteotomy of the humerus which can be combined with transfer of the teres major and latissimus dorsi. II. Retro- and infraclavicular lesions of the brachial plexus. Twenty-five percent of the lesions of the brachial plexus occur in the retro- or infraclavicular region and involve the secondary trunks, most commonly the posterior trunk. Nerve repair should be performed early. The shoulder may be affected owing to involvement of the axillary nerve in cases of lesions of the posterior trunk, often associated with a lesion of the suprascapular nerve. Regarding the terminal branches (axillary, suprascapular and musculocutaneous nerves), spontaneous recovery may be expected in a significant proportion of cases but is often delayed (6-9 months), and the problem is to avoid unnecessary operations while not unduly delaying surgical repair in cases where it is indicated. MRI may be useful to delineate those cases where surgery is indicated: repair is usually performed around 6 months following trauma. Isolated lesions of the axillary nerve may be repaired with good results using a nerve graft. The lesion may occur in combination with a lesion of the suprascapular nerve; the latter may be interrupted at several levels. Proximal repair may be performed using a nerve graft; distal lesions are more difficult to repair and may require intramuscular neurotization. Lesions of the musculocutaneous nerve may be repaired with good results using a nerve graft. Lesions of the axillary nerve may be seen associated with lesions of the rotator cuff. The treatment varies according to the age and condition of the patient and according to the condition of the cuff muscles and tendons: in a young patient with avulsion of the tendons from bone, cuff reinsertion is indicated; in an older patient, the cuff must be evaluated by MRI or arthroscan, and repair is indicated unless the cuff tear is not amenable to surgery or there is fatty degeneration of the muscles. Palliative surgery may be indicated in cases seen late or after failed attempts at nerve repair. (ABSTRACT     

Nerve transfer for treatment of brachial plexus injury：comparison study between the transfer of partial median and ulnar nerves and that of phrenic and spinal accessary nerves

Objective:To compare the effect of using partial median and ulnar nerves for treatment of C5-6 orC5-7 avulsion of the brachial plexus with that of using phrenic and spinal accessary nerves.Methods:The patients were divided into 2groups randomly according to different surgical procedures.Twelve cases were involved in the first group.The phrenic nerve was transferred to the musculocutaneous nerve or through a sural nerve graft,and the spinal accessary nerve was to the suprascapular nerve.Eleven cases were classified into the second group.A part of the fascicles of median nerve was transferred to be coapted with the motor fascicle of musculocutaneous nerve and a part of fascicles of ulnar nerve was transferred to the axillary nerve.The cases were followed up from 1to 3years and the clinical outcome was compared between the two groups.     

Nerve transfer in brachial plexus injuries--comparative analysis of surgical procedures

Nerve transfer is the only possibility for nerve repair in cases of the brachial plexus traction injuries with spinal roots avulsion. From 1980. until 2000. in Institute of Neurosurgery, Clinical Center of Serbia, nerve transfer has been performed in 127(79%) of 159 patients with traction injuries of brachial plexus, i.e., 204 reinnervation procedures has been performed using different donor nerves. We achieved good or satisfactory arm abduction and full range or satisfactory elbow flexion through reinnervation of the axillary and musculocutaneous nerve using different donor nerves in 143 of 204 reinnervations, which presents general rate of useful functional recovery in 70.1% of cases. Mean values of the rate of useful functional recovery in individual modalities of nerve transfer in our series are 50.1% for intercostal and/or spinal accessory nerve transfer, 64.5% for plexo-plexal nerve transfer, 81.7% for regional nerve transfer, and 87.1% for combine nerve transfer.     

健侧颈7神经根移位同时修复两条神经的初步临床疗效

目的探讨用健侧颈，神经根移位同时修复2条上肢神经的临床效果。方法设计2种移位修复的方法。(1)合干法：健侧颈，前后股→尺神经→尺神经近端分2股分别和正中神经、桡神经(或肌皮神经)缝合，共5例。(2)分干法：健侧颈前后股→尺神经、腓肠神经→正中神经、桡神经(或肌皮神经)，共3例。结果合干法4例术后随访12～19个月，1例尚在随访中。正中神经运动：2例已恢复屈腕、屈指，肌力M3。2例屈腕肌力为M1。正中神经感觉：3例为S2，1例为S0。桡神经运动：2例伸腕、伸指肌力为M2。1例伸肘肌力为M2，1例伸腕肌力为M1。桡神经感觉：1例为S2，1例为S1，2例为S0。分干法1例术后随访15个月，已恢复屈腕、屈指，肌力为M3。正中神经感觉为是。肌皮神经：屈肘肌力为M3。另2例术后时间短尚在随访中。结论健侧颈，神经根移位同时修复上肢2条主要神经的新术式，初步应用结果证实是可行的、有效的。     

肋间神经移位治疗全臂丛根性撕脱伤两种术式的比较

目的　比较肋间神经移位直接与肌皮神经缝合 ,和通过皮神经移植桥接肌皮、肋间神经两种术式的疗效。方法　 3 2例全臂丛根性撕脱伤 ,其中将肋间神经游离 10～ 13cm ,经电刺激证实含有运动神经束后切断 ,与肌皮神经直接缝合 2 0例。在肋间神经与肌皮神经间移植皮神经 (平均长 10 .2cm) 12例。术后平均随访 3年 ,观察肱二头肌屈肘功能及肌力的恢复。结果　肌力达 3级或 3级以上的 ,神经移位组占 75 % ,神经移植组为 2 5 %。结论　肋间神经与肌皮神经缝接后 ,屈肘功能恢复明显 ,直接缝合组优于神经移植桥接组 (P <0 .0 1)。     

Transfer of pectoral nerves to the musculocutaneous nerve in obstetric upper brachial plexus palsy

OBJECTIVE: To investigate the results of transfer of pectoral nerves to the musculocutaneous nerve for treatment of obstetric brachial palsy. METHODS: In 25 cases of obstetric brachial palsy (20 after breech deliveries), branches of the pectoral nerve plexus were transferred directly to the musculocutaneous nerve. For all patients, the nerve transfer was part of an extended brachial plexus reconstruction. Results were tested both clinically and with the Mallet scale, at a mean follow-up time of 70 months (standard deviation, 34.3 mo). RESULTS: There were two complete failures, which were attributable to disconnection of the transferred nerve endings. The results after transfer were excellent in 17 cases and fair in 5 cases. Steindler flexorplasty improved elbow flexion for three patients. CONCLUSION: Transfer of pectoral nerves to the musculocutaneous nerve for treatment of obstetric upper brachial palsy may be effective, if the specific anatomic features of the pectoral nerve plexus are sufficiently appreciated.     

Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients.

Intercostal nerve transfer is a well-established and effective technique for irreparable avulsed brachial plexus injuries. Between 1987 and 1989, 66 patients with brachial plexus injuries were treated by means of intercostal nerve transfer to the musculocutaneous nerve, with or without nerve grafts to obtain elbow flexion. The results were evaluated. Five clinical signs--(1) induction of chest pain by squeezing of biceps, (2) proximal biceps contraction, (3) distal biceps contraction, (4) active elbow flexion against gravity, and (5) active elbow flexion against weight--were identified and used as a guide for functional recovery. The overall success rate with motor function of grade 4 or more was 67%. The motor results were better in 1989 (81%) because of greater familiarity with the anatomy and improved surgical technique. The important factors in obtaining a good result are (1) early exploration (less than 5 months after trauma), (2) use of three intercostal nerves, (3) mixed nerve-to-mixed nerve coaptation, (4) nerve repair without grafts and under no tension, and (5) shoulder stability.     

Radial plus musculocutaneous nerve stimulation for axillary block is inferior to triple nerve stimulation with 2% mepivacaine

STUDY OBJECTIVE: To compare the extent of sensory and motor block with two different nerve stimulation techniques in axillary blocks. DESIGN: Prospective, randomized, investigator-blinded study. SETTING: Ambulatory surgery unit of a university hospital. PATIENTS: 60 ASA physical status I, II, and III patients undergoing surgery at or below the elbow. INTERVENTIONS: Patients receiving axillary block were randomized into two nerve stimulation groups with either radial plus musculocutaneous or triple nerve stimulation (radial, median, and musculocutaneous nerves). Thirty milliliters of plain 2% mepivacaine was given to all patients either in a single or fractionated dosing for radial or for radial and median nerves, according to group assignment. Five milliliters of plain 1% mepivacaine for the musculocutaneous nerve was given to all patients. MEASUREMENTS: Blocks were assessed at 10, 20, and 30 minutes. Rates of supplementation given as a result of insufficient surgical anesthesia were also noted. MAIN RESULTS: Statistically significantly higher rates of anesthesia at the cutaneous distributions of median and medial cutaneous of the arm nerves with multiple nerve stimulation at 30 minutes were found as compared with radial plus musculocutaneous nerve stimulation. The rate of supplementation was lower with multiple nerve stimulation. CONCLUSIONS: Radial plus musculocutaneous nerve stimulation showed lower efficacy of axillary block than did triple nerve stimulation when using 2% mepivacaine.     

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.     

Restoration of Elbow Flexion by Transfer of the Phrenic Nerve to Musculocutaneous Nerve after Brachial Plexus Injuries

Traumatic brachial plexus injuries are a devastating injury that results in partial or total denervation of the muscles of the upper extremity. Treatment options that include neurolysis, nerve grafting, or neurotization (nerve transfer) has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. In the present study, we analyze the results obtained in 20 patients treated with phrenic–musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries. A consecutive series of 25 adult patients (21 men and 4 women) with a brachial plexus traction/crush lesion were treated with phrenic–musculocutaneous nerve transfer, but only 20 patients (18 men and 2 women) were followed and evaluated for at least 2 years postoperatively. All patients had been referred from other institutions. At the initial evaluation, eight patients received a diagnosis of C5-6 brachial plexus nerve injury, and in the other 12 patients, a complete brachial plexus injury was identified. Reconstruction was undertaken if no clinical or electrical evidence of biceps muscle function was seen by 3 months post injury. Functional elbow flexion was obtained in the majority of cases by phrenic–musculocutaneous nerve transfer (14/20, 70%). At the final follow-up evaluation, elbow flexion strength was a Medical Research Council Grade 5 in two patients, Grade 4 in four patients, Grade 3 in eight patients, and Grade 2 or less in six patients. Transfer involving the phrenic nerve to restore elbow flexion seems to be an appropriate approach for the treatment of brachial plexus root avulsion. Traumatic brachial plexus injury is a devastating injury that result in partial or total denervation of the muscles of the upper extremity. Treatment options include neurolysis, nerve grafting, or neurotization (nerve transfer). Neurotization is the transfer of a functional but less important nerve to a denervated more important nerve. It has become an important procedure in the restoration of function in patients with irreparable preganglionic lesions. Restoration of elbow flexion is the primary goal in treating patients with severe brachial plexus injuries. Nerve transfers are used when spinal roots are avulsed, and proximal stumps are not available. Newer extraplexal sources include the ipsilateral phrenic nerve as reported by Gu et al. (Chin Med J 103:267–270, 1990) and contralateral C7 as reported by Gu et al. (J Hand Surg [Br] 17(B):518–521, 1992) and Songcharoen et al. (J Hand Surg [Am] 26(A):1058–1064, 2001). These nerve transfers have been introduced to expand on the limited donors. The phrenic nerve and its anatomic position directly within the surgical field makes it a tempting source for nerve transfer. Although not always, in cases of complete brachial plexus avulsion, the phrenic nerve is functioning as a result of its C3 and C4 major contributions. In the present study, we analyze the results obtained in 20 patients treated with phrenic–musculocutaneous nerve transfer to restore elbow flexion after brachial plexus injuries.     

多组神经移位治疗臂丛上、中干根性撕脱伤重建肩外展及屈肘功能

目的 观察联合应用多组神经移位治疗臂丛上、中干根性撕脱伤的临床效果。方法 我科于2012年4月至2014年4月收治臂丛上、中干根性撕脱伤损伤患者16例,采用副神经斜方肌肌支移位修复肩胛上神经、桡神经肱三头肌长头支移位修复腋神经肌支及Oberlin术式,联合修复臂丛上、中干根性撕脱伤,恢复肩外展及屈肘功能。术后随访采用DASH评分表进行手术疗效评估。结果 术后16例患者中14例得到随访。随访24—28个月(平均25个月),患者肩关节外展恢复至75°-90°,恢复时间9-18个月(平均14个月)。屈肘恢复至100°-160°,恢复时间4-7.5个月（平均5.8个月）。DASH评分8-14分,平均14.6分。结论 臂丛上、中干损伤使用多组神经移位联合治疗,可较好恢复肩外展及屈肘功能,尺神经部分束支移位修复肌皮神经肱二头肌支对手内在肌功能无明显影响。     

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.     

Injuries of the terminal branches of the infraclavicular brachial plexus: patterns of injury, management and outcome

We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves.     

Initial report on the limited value of hypoglossal nerve transfer to treat brachial plexus root avulsions.

OBJECT: Hypoglossal nerve (12th cranial nerve) transfer was performed to treat the sequelae of brachial plexus root avulsion in 12 adults and two infants, and the patients were followed to assess the effectiveness of the surgery. METHODS: The 12th cranial nerve was transected at the base of the tongue, and a sural nerve graft was used to bridge the gap between the donor (12th) and recipient nerves: C-5 spinal, axillary, suprascapular, or musculocutaneous nerve. The mean graft length in adult patients was 15.75 +/- 5.5 cm (+/- standard deviation, median 14.5 cm) and in the two infants the graft lengths were 7 and 8 cm, respectively. After a mean postoperative interval of 1138 +/- 254 days, electromyographic examination of the target muscles showed tongue movement-related activity in all patients. Muscle force strength measured according to the Medical Research Council's guidelines, was Grade 3 or higher in 21% of patients. Contraction, however, could only be attained by tongue movements, and volitional control was not achieved. CONCLUSIONS: Although recovery of muscle strength was obtained by 12th cranial nerve transfer, the functional gain remained virtually nonexistent because central control was missing.     

Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfers

Between 1993 and 1998, 32 male patients with brachial plexus injuries were surgically treated. Eighteen interfascicular grafting and 71 extraplexal neurotization procedures were performed separately or in combination. Donor nerves were the intercostals, spinal accessory, phrenic, contralateral C7, and cervical plexus, in order of frequency. Patients were followed for a minimum of 24 (average, 35) months. Biceps function was best following grafting the musculocutaneous nerve itself, or neurotization with the phrenic nerve (100 percent grade 4), followed by neurotization with the intercostals (89.5 percent grade 3 or more) and last, grafting the C5 root or upper trunk (grade 3 in one of three patients). Phrenic to suprascapular neurotization produced the best results of shoulder abduction (40 to 90 degrees), followed by combined neurotization of the spinal accessory to suprascapular and phrenic to axillary (20 to 90 degrees). Sensory recovery over the lateral forearm and palm varied from S2 to S3+, according to the method of reconstruction.     

Repair of brachial plexus lesions by end-to-side side-to-side grafting neurorrhaphy: experience based on 11 cases

Eleven brachial plexus lesions were repaired using end-to-side side-to-side grafting neurorrhaphy in root ruptures, in phrenic and spinal accessory nerve neurotizations, in contralateral C7 neurotization, and in neurotization using intact interplexus roots or cords. The main aim was to approximate donor and recipient nerves and promote regeneration through them. Another indication was to augment the recipient nerve, when it had been neurotized or grafted to donors of dubious integrity, when it was not completely denervated, when it had been neurotized to a nerve with a suboptimal number of fibers, when it had been neurotized to distant donors delaying its regeneration, and when it had been neurotized to a donor supplying many recipients. In interplexus neurotization, the main indication was to preserve the integrity of the interplexus donors, as they were not sacrificeable. The principles of end-to-side neurorrhaphy were followed. The epineurium was removed. Axonal sprouting was induced by longitudinally slitting and partially transecting the donor and recipient nerves, by increasing the contact area between both of them and the nerve grafts, and by embedding the grafts into the split predegenerated injured nerve segments. Agonistic donors were used for root ruptures and for phrenic and spinal accessory neurotization, but not for contralateral C7 or interplexus neurotization. Single-donor single-recipient neurotization was successfully followed in phrenic neurotization of the suprascapular (3 cases) and axillary (1 case) nerves, spinal accessory neurotization of the suprascapular nerve (1 case), and dorsal part of contralateral C7 neurotization of the axillary nerve (2 cases). Apart from this, recipient augmentation necessitated many donor to single-recipient neurotizations. This was successfully performed using phrenic-interplexus root to suprascapular transfers (2 cases), phrenic-contralateral C7 to suprascapular transfer (1 case), and spinal accessory-interplexus root to musculocutaneous transfer (1 case). Both recipient augmentation and increasing the contact area between grafts and recipients necessitated single or multiple donor to many recipient neurotizations. This was applied in root ruptures (3 cases), with results comparable to those obtained in classical nerve-grafting techniques. It was also applied in ventral C7 transfer to the lateral or medial cords (3 cases) with functional recovery occurring in the biceps and pronator teres muscles, but not in dorsal C7 transfer to the axillary and radial nerves (3 cases) with functional recovery occurring in the deltoid and triceps muscles, and in whole C7 transfer to C5, 6, 7, 8T1 roots with functional recovery occurring in the deltoid (M4), biceps (M4), pronator teres (M4), and triceps (M3) (3 cases), and less so in the flexor carpi ulnaris and FDP (M3) (1 case) and the extensor digitorum longus (M3) (1 case). Contralateral C7 transfer to the lateral and posterior cords (4 cases) was followed by cocontractions that took 1 year to improve and that involved the rotator cuff, deltoid, biceps, and pronator teres (all agonists). Functional recovery in the triceps muscle was less than in the above muscles. Contralateral C7 transfer to C5-7 (1 case) was followed by cocontractions that took 1 year to resolve and that occurred between the deltoid, biceps, and flexor digitorum profundus. Interplexus root neurotization was done only in conjunction with other neurotization techniques, and so its role is difficult to judge. Though the same applies to regenerated lateral cord transfer to the posterior cord (2 cases), the successful results obtained from medial cord neurotization to the axillary, musculocutaneous, and radial nerves (1 case), and from ulnar and median nerve neurotization to the radial nerve (1 case), show that neurotization at the interplexus cord level may play a role in brachial plexus regeneration and may even be used to neurotize nerves and muscles distal to the elbow. The timing of repair was within 6 months after injury, except for 2 cases. In the first case, contralateral C7 transfer was successfully performed more than 1 year after injury. The second case was an obstetric palsy operated upon at age 8. Deterioration in motor power of the donor muscles that improved in 6 months was observed in 2 cases of interplexus neurotization at the cord level, because of looping the sural nerve grafts tightly around the donor nerves. Deterioration in donor-muscle motor power as a consequence of end-to-side neurorrhaphy was noted in the obstetric palsy case, when the flexor carpi radialis (donor) became grade 3 instead of grade 4. This was associated with cocontractions between it and the extensors. It took nearly 1 year to improve.