Intercostal nerve transfer to the biceps motor branch in complete traumatic brachial plexus injuries

The purpose of this report is to critically evaluate our results of two intercostal nerve transfers directly to the biceps motor branch in complete traumatic brachial plexus injuries. From January 2007 to November 2012, 19 patients were submitted to this type of surgery, but only 15 of them had a follow‐up for ≥2 years and were included in this report. The mean interval from trauma to surgery was 6.88 months (ranging from 3 to 9 months). Two intercostals nerves were dissected and transferred directly to the biceps motor branch. The mean follow‐up was 38.06 months (ranging from 24 to 62 months). Ten patients (66.6%) recovered an elbow flexion strength ≥M3. Four of them (26.66%) recovered a stronger elbow flexion ≥M4. One patient (6.25%) recovered an M2 elbow flexion and four patients (26.66%) did not regain any movement. We concluded that two intercostal nerve transfers to the biceps motor branch is a procedure with moderate results regarding elbow flexion recovery, but it is still one of the few options available in complete brachial plexus injuries, especially in five roots avulsion scenario. © 2015 Wiley Periodicals, Inc. Microsurgery 35:428–431, 2015.     

One-fascicle median nerve transfer to biceps muscle in C5 and C6 root avulsions of brachial plexus injury

Five male patients with avulsions of the C5 and C6 roots of the brachial plexus underwent transfer of one fascicle of the median nerve to the motor branch of the biceps muscle. The mean period of follow-up was 32 months. The average reinnervation time of the biceps was 3.4 months. Four patients achieved biceps strength of Medical Research Council (MRC) grade 4, and one patient had strength of the biceps of MRC grade 3. The mean period of time from surgery to MRC grade 3 was 9 months. At the last follow-up examination, grip strength, pinch strength, moving two-point discrimination, and strength of wrist volar flexion on the affected side were not worse than before the operation in any patient.     

旋后肌肌支移位术的解剖学研究

目的 通过对桡神经旋后肌肌支和骨间后神经的显微解剖,为旋后肌肌支移位术提供解剖学依据,并设计旋后肌肌支移位术的最佳手术入路.方法 选择13侧甲醛固定成人上肢标本,解剖肘以远桡神经及各肌支,记录旋后肌肌支及骨间后神经的形态特征、分布情况和直径.结果 旋后肌肌支一般有3支,旋后肌Frohse弓近端2支,旋后肌肌管内1支,管外肌支恒定,可直接与骨间后神经缝合,且口径匹配.结论 旋后肌肌支可用来移位修复骨间后神经,为臂丛神经中下干损伤患者提供一种新的神经移位方式.     

Comparison of objective muscle strength in c5‐c6 and c5‐c7 brachial plexus injury patients after double nerve transfer

Purpose: The purpose of this study was to evaluate the quantitative muscle strength to distinguish the outcomes of different injury levels in upper arm type brachial plexus injury (BPI) patients with double nerve transfer. Methods: Nine patients with C5‐C6 lesions (age = 32.2 ± 13.9 year old) and nine patients with C5‐C7 lesions (age = 32.4 ± 7.9 year old) received neurotization of the spinal accessory nerve to the suprascapular nerve combined with the Oberlin procedure (fascicles of ulnar nerve transfer to the musculocutaneous nerve) were recruited. The average time interval between operation and evaluation were 27.3 ± 21.0 and 26.9 ± 20.6 months for C5‐C6 and C5‐C7, respectively. British Medical Research Council (BMRC) scores and the objective strength measured by a handheld dynamometer were evaluated in multiple muscles to compare outcomes between C5‐C6 and C5‐C7 injuries. Results: There were no significant differences in BMRC scores between the groups. C5‐C6 BPI patients had greater quantitative strength in shoulder flexor (P = 0.02), shoulder extensor (P < 0.01), elbow flexor (P = 0.04), elbow extensor (P = 0.04), wrist extensor (P = 0.04), and hand grip (P = 0.04) than C5‐C7 BPI patients. Conclusions: Upper arm type BPI patients have a good motor recovery after double nerve transfer. The different outcomes between C5‐C6 and C5‐C7 BPI patients appeared in muscles responding to hand grip, wrist extension, and sagittal movements in shoulder and elbow joints. © 2014 Wiley Periodicals, Inc. Microsurgery 35:107–114, 2015.     

The prespinal route in contralateral C7 nerve root transfer for brachial plexus avulsion injuries

Contralateral C7 nerve root transfer for brachial plexus injury is described, passing the nerve through a subcutaneous tunnel on the anterior surface of the neck and chest. We recommend passing the nerve graft through the retropharyngeal space. This route has the benefits of a simpler dissection, a shorter distance and protected placement of the graft. It has been used in one clinical case.     

Transfer of brachioradialis motor branch to the anterior interosseous nerve in C8‐T1 brachial plexus palsy. An anatomic study

We present an anatomical and histomorphometric study of the transfer of the motor branch to the brachioradialis muscle to the anterior interosseous nerve in recent brachial plexus lesions, involving C8 and T1 roots. The aim of this study was to demonstrate the anatomic constancy of the nerves involved in the transfer, feasibility, and reproducibility of the transfer. We performed a study of 14 elbows in fresh cadavers. Transfer of the motor branch of the brachioradialis muscle to the anterior interosseous nerve was possible in all specimens; there was constancy in the origin and entry into the muscle of the donor nerve, and it was always possible to dissect the recipient nerve at the level of the donor nerve, thereby allowing for direct coaptation of the nerves. The mean diameter of the anterior interosseous nerve was 2.9 ± 0.5 mm and the mean diameter of the brachioradialis muscle branch was 2 ± 0.4 mm. The branch to the brachioradialis muscle contains an average of 550 ± 64 myelinated axons and the anterior interosseous nerve has an average of 2266 ± 274 myelinated axons. The anatomic study in cadavers showed that the technique is justified and anatomically reproducible. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

健侧颈7神经经椎体前路移位直接修复臂丛根部撕脱伤

目的 探讨健侧C7神经经椎体前路移位、一期直接修复臂丛根部撕脱伤的临床疗效.方法 对臂丛根性撕脱伤伤后1～3个月行健侧C7神经经椎体前路移位直接修复术16例.在健侧C7神经前、后股汇入外侧束、后束平面后作显微解剖分离以切取健侧C7的最大长度.健侧C7神经均可顺利经前斜角肌内侧隧道-椎体前路引至患侧,一期与患侧C8、T1-下干直接缝合10例,与患侧C5、6-上千直接缝合4例,与患侧C6、C8神经根直接缝合2例.结果 健侧C7根干前、后股切取长度分别为(7.71±1.16)和(6.97±1.18)cm.一期直接修复c8、T1-下干组经6～18个月随访8例,术后6个月尺、正中神经Tinel征阳性平面至肘关节.有2例术后9个月胸大肌胸肋部收缩(M3),术后12～18个月,手掌、手指与前臂内侧均有触痛觉恢复,尺侧腕屈肌和示、中、环、小指屈肌收缩(M3).结论 健侧颈7神经经椎体前路移位、一期直接修复C8、T1-下干的手术设计具有可操作性,是治疗臂丛根部撕脱伤的有效方法.     

Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus

We applied a nerve transfer, using the ipsilateral C7 nerve root to treat the C5 and C6 root avulsion of the brachial plexus. Four patients with C5 and C6 preganglionic injury were operated on with this new technique from 1998-2000. Transfer of the spinal accessory nerve to the suprascapular nerve was simultaneously done in 2 these patients. After a follow-up of 1-2.5 years, the muscle strength of elbow flexors recovered to M4 (Lovett) in all cases, shoulder abduction of >90 degrees with external rotation of 30-40 degrees was gained in two cases, and that of 15-45 degrees with no external rotation in the other two cases. No remarkable impairment was found in all C7-innervated muscles except for decrease of muscle power of 1 grade (Lovett) in the short run. This new technique shows promise as an efficacious and safe treatment for C5 and C6 root avulsion of the brachial plexus. However, it should be applied prudently when incomplete injuries of the lower trunk are involved.     

Technique of the double nerve transfer to recover elbow flexion in C5, C6, or C5 to C7 brachial plexus palsy

In C5, C6, or C5-to-C7 root injuries, many surgical procedures have been proposed to restore active elbow flexion. Nerve grafts or nerve transfers are the main techniques being carried out. The transfer of ulnar nerve fascicles to the biceps branch of the musculocutaneous nerve is currently proposed to restore active elbow flexion. Recovery of biceps muscle function is generally sufficient to obtain elbow flexion. However, the strength of elbow flexion is sometimes weak because the brachialis muscle is not reinnervated. Therefore, the transfer of 1 fascicle of the median nerve to the brachialis branch of the musculocutaneous nerve may be proposed to improve strength of the elbow flexion. We describe the technique of this double transfer to restore elbow flexion. The results concerning 5 patients are presented.     

同侧C7神经根移位治疗臂丛上干根性撕脱伤

多组神经移位是治疗臂丛神经损伤最常用的方法，而膈神经是最佳的动力神经之一。临床研究发现臂丛根性撕脱伤中的11％-13％合并上肢各神经损伤。对这部分病例，采用什么动力神经移位修复最好呢?蔡佩琴等用同侧C7神经根移位取得了成功。1999年4月-2001年10月，我们对3例臂丛上干根性撕脱伤患者，采用同侧C7神经根移位至上干远端，取得了良好的疗效。     

Surgical treatment for total root avulsion type brachial plexus injuries by neurotization: A prospective comparison study between total and hemicontralateral C7 nerve root transfer

Purpose: We conducted a clinical study to evaluate the effects of neurotization, especially comparing the total contralateral C7 (CC7) root transfer to hemi‐CC7 transfer, on total root avulsion brachial plexus injuries (BPI). Methods: Forty patients who received neurotization for BPI were enrolled in this prospective study. Group 1 (n = 20) received hemi‐CC7 transfer for hand function, while group 2 (n = 20) received total‐CC7 transfer. Additional neurotization included spinal accessory, phrenic, and intercostal nerve transfer for shoulder and elbow function. The results were evaluated with an average of 6 years follow‐up. Results: Group 1 had fewer donor site complications (15%) than group 2 (45%); group 2 had significantly better hand M3 and M4 motor function (65%) than group 1 (30%; P = 0.02). There was no difference in sensory recovery. Significantly, better shoulder function was obtained by simultaneous neurotization on both suprascapular and axillary nerves. Conclusions: Total‐CC7 transfer had better hand recovery but more donor complications than hemi‐CC7. Neurotization on both supra‐scapular and axillary nerves improved shoulder recovery. © 2013 The Authors. Microsurgery published by Wiley Periodicals, Inc. Microsurgery 34:91–101, 2014.     

Transfer of a flexor digitorum superficialis motor branch for wrist extension reconstruction in C5–C8 root injuries of the brachial plexus: A case series

In brachial plexus injuries, though nerve transfers and root grafts have improved the results for shoulder and elbow reconstruction, wrist extension has received little attention. We operated on three young patients with C5–C8 root injuries of the left brachial plexus, each operated upon within 6 months of trauma. For wrist extension reconstruction, we transferred a proximal branch of the flexor digitorum superficialis to the motor branch of the extensor carpi radialis brevis. Twenty‐four months after surgery, all patients recovered some degree of active wrist motion, from full flexion to near neutral. Independent control of finger flexion and wrist extension was not observed. In C5–C8 root injuries of the brachial plexus, transfer of a flexor digitorum superficialis motor branch to the extensor carpi radialis brevis produces limited recovery. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve

PURPOSE: In C5 and C6 brachial plexus avulsion lesions, elbow flexion, shoulder abduction, and external rotation are the functions that need to be restored. Because the proximal stumps are not available for grafting, surgical repair is based on nerve transfers. The purpose of this study was to describe and report the results of the use of multiple nerve transfers in the reconstruction of these avulsion injuries. METHODS: Ten patients had multiple nerve transfers: cranial nerve XI to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps long or lateral head motor branch to the axillary nerve. Triceps branch transfer was performed through a posterior arm incision. RESULTS: Two years after surgery, all the patients had recovered full elbow flexion; 7 scored M4 and 3 scored M3+ according to Medical Research Council scoring. All the patients had recovered active abduction and external rotation. Abduction recovery averaged 92 degrees (range, 65 degrees-120 degrees) and external rotation, measured from full internal rotation, averaged 93 degrees (range, 80 degrees-120 degrees). Shoulder abduction strength was graded M4 in 3 patients and M3 in the remaining 7 patients. Shoulder external rotation strength was graded M4 in 2 patients, M3 in 5 patients, and M2 in 3 patients. No donor site deficits were observed. CONCLUSIONS: The proposed nerve transfers constitute a valid strategy in C5-C6 avulsion injury reconstruction.     

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.     

Functional compensative mechanism of upper limb with root avulsion of C5-C6 of brachial plexus after ipsilateral C7 transfer

Objective： To investigate the compensative mechanism of no further impairment of the upper limb after ipsilateral C7 transfer for treatment of root avulsion of C5-C6 of the brachial plexus.
Methods： Sixty Sprague Dawley （SD） rats were randomly divided into a CT-transection group and a control group, 30 rats each. In the CT-transection group, the left forelimbs of the animals underwent transection of ipsilateral C7 nerve root while C5 and C6 nerve roots were avulsed. In the control group, the left forelimbs only underwent C5 and C6 root avulsion. The representative muscles of C7 （innervated mainly by C7） including latissimus dorsi, triceps, extensor carpi radialis brevis and extensor digitorum communis were evaluated with neurophysiological investigation, muscular histology and motor end plate histomorphometry 3, 6 and 12 weeks after operation. The right forelimbs of all rats were taken as the control sides.
Results： Three weeks after operation, the recovery rates of amplitudes of compound muscle action potential （CMAP） and CMAP latency, muscular wet weight and cross-sec- tional area of muscle fibers, and area of postsynaptic membranes of those four representative muscles in the C7- transection group were significantly lower than those of the control group （P 〈0.05 or P 〈0.01）. Six weeks postoperatively, the recovery rates of CMAP amplitude and latency of the triceps showed no significant difference between the C7- transection group and the control group （P〉0.05）. For theextensor carpi radialis brevis and the extensor digitorum communis, the recovery rates of the cross-sectional area of muscle fibers, the amplitude and latency of CMAP and the area of postsynaptic membranes showed no significant dif- ference between the two groups （P 〉0.05）, while the rest parameters were still significantly different between the two group （P 〈0.05 or P 〈0.01）. As far as the ultramicrostructure was concerned in the CT-transection group, more motor end plates of four representative m     

健侧C7神经经椎体后通路治疗臂丛神经根性撕脱伤的解剖学研究

目的通过解剖学研究,探讨健侧C7神经经椎体后通路移位治疗对侧臂丛神经根性撕脱伤的可行性。方法取10具甲醛固定的成人尸体标本,其中男7具,女3具,标本均无明显畸形,组织无缺损,颈部中立位。模拟臂从神经损伤手术探查方式,将C₇神经根的前、后股向远端行干支分离使其长度增加后再切断,同时测量C₇神经根自椎间孔发出至分股处长度及其前、后股长度;模拟颈椎后路手术入路,充分暴露C₇颈椎及T₁棘突,并于其间靠近椎体侧钻孔,测最经椎体后通路达对侧臂丛神经上干与下干距离。结果 C₇神经根长度为（58.62±8.70）mm,加后股长度为（65.15±9.11）mm,加前股长度为（70.03±10.79）mm。经椎体后通路C₇神经根至对侧臂丛神经上干距离为（72.12±10.22）mm,至对侧臂丛神经下干距离为（95.21±12.50）mm。结论健侧C₇神经可以经椎体后通路移位至对侧,不需要或仅需一小段桥接神经,该通路能有效避免经椎体前路损伤血管、神经等并发症,可能成为治疗臂丛神经根性撕脱伤的有效入路。     

健侧C7神经根经椎体前通路移位修复臂丛神经损伤疗效的初步观察

目的：观察经椎体前通路行健侧C7神经根移位修复臂丛神经损伤的临床效果。方法：将健侧C7神经根在干股交界处切断，近端游离至椎间孔处，经前斜角肌的深面翻转至椎体前食管后间隙，经4-6股皮神经桥接，修复患侧上干或上干后股。2002年3月-2003年8月，共完成21例手术，其中14例术后随访1年以上。14例中男12例，女2例；年龄17-41岁，平均31岁。手术时间：伤后2～6个月，平均4个月。全臂丛神经撕脱伤5例，上中干撕脱伴下干不全损伤8例，上中干锐器伤1例。结果：14例患者术后随访12～19个月，平均16个月。健侧C7神经根修复患侧上干或C5、C6神经根或上干前后股的10例，9例肩外展及屈肘肌肌力≥3级，1例无效；健侧C7神经根修复患侧上干后股或C5神经根的3例，肩外展肌肌力均≥3级；健侧C7神经根修复C6神经根1例，肱二头肌肌力为0级。结论：健侧C7神经根经椎体前通路移位修复臂丛神经上干的同时重建肩外展及屈肘功能或修复上干后股重建肩外展功能，可取得良好疗效。