Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy

BACKGROUND: The transfer of one or more ulnar nerve fascicles to the nerve to the biceps can restore elbow flexion in patients with upper brachial plexus palsy. The purposes of the present retrospective study were to evaluate the results of this procedure, to measure the delay in reinnervation of the biceps muscle, and to define the indications for a secondary Steindler flexorplasty. METHODS: Thirty-two patients with an upper nerve-root brachial plexus injury were reviewed at an average of thirty-one months after the nerve fascicle transfer. The average age of the patients was twenty-eight years. The average time between the injury and the operation was nine months. Patients were evaluated with regard to reinnervation of the biceps, ulnar nerve function, elbow flexion strength, and grip strength. RESULTS: The average time required for reinnervation of the biceps after nerve fascicle transfer was five months. No motor or sensory deficits related to the ulnar nerve were noted clinically. The average grip strength at the time of the last follow-up was 25 kg (an improvement of 9 kg compared with the preoperative value). After the nerve transfer, twenty-four patients achieved grade-3 elbow flexion strength or better according to the grading system of the Medical Research Council. A Steindler flexorplasty was performed as a secondary procedure in ten patients with persistent grade-3 flexor strength or worse. In eight of these cases, elbow flexion strength improved after nerve transfer and flexorplasty. Overall, thirty of the thirty-two patients achieved a good result (grade-4 strength) or a fair result (grade-3 strength). CONCLUSIONS: We recommend this procedure for brachial plexus injuries involving the C5-C6 or C5-C6-C7 nerve roots. This procedure spares the C5 nerve root and other nerves for grafting or transfer elsewhere. A secondary Steindler flexorplasty is indicated for patients who have persistent grade-3 elbow flexion strength or worse for at least twelve months after nerve fascicle transfer.     

Axillary nerve repair by fascicle transfer from the ulnar or median nerve in upper brachial plexus palsy

Object Nerve repair using motor fascicles of a different nerve was first described for the repair of elbow flexion (Oberlin technique). In this paper, the authors describe their experience with a similar method for axillary nerve reconstruction in cases of upper brachial plexus palsy. Methods Of 791 nerve reconstructions performed by the senior author (P.H.) between 1993 and 2011 in 441 patients with brachial plexus injury, 14 involved axillary nerve repair by fascicle transfer from the ulnar or median nerve. All 14 of these procedures were performed between 2007 and 2010. This technique was used only when there was a deficit of the thoracodorsal or long thoracic nerve, which are normally used as donors. Results Nine patients were followed up for 24 months or longer. Good recovery of deltoid muscle strength was seen in 7 (77.8%) of these 9 patients, and in 4 patients with less follow-up (14-23 months), for an overall success rate of 78.6%. The procedure was unsuccessful in 2 of the 9 patients with at least 24 months of follow-up. The first showed no signs of reinnervation of the axillary nerve by either clinical or electromyographic evaluation in 26 months of follow-up, and the second had Medical Research Council (MRC) Grade 2 strength in the deltoid muscle 36 months after the operation. The last of the group of 14 patients has had 12 months of follow-up and is showing progressive improvement of deltoid muscle function (MRC Grade 2). Conclusions The authors conclude that fascicle transfer from the ulnar or median nerve onto the axillary nerve is a safe and effective method for reconstruction of the axillary nerve in patients with upper brachial plexus injury.     

Functional outcome of ulnar nerve fascicle transfer for restoration of elbow flexion in upper brachial plexus injury

Introduction  

Upper part brachial plexus injuries result in paralysis of Biceps and inability of active elbow flexion. If repair of damaged nerves proves to be impossible, reconstruction surgery will be indicated. Oberlin procedure is a reconstructive method for restoration of elbow flexion in which, posteromedial fascicle of ulnar nerve is transferred to the motor nerve of Biceps. In this article, we evaluated the results of this procedure in 10 patients in whom treatment was performed relatively late.     

尺神经部分转位肌皮神经二头肌支治疗早晚期臂丛神经损伤

[目的]臂丛神经上中干损伤的修复治疗中肘屈曲功能是最为重要的.在已有的几种恢复肘关节屈曲功能的神经转位手术中,部分尺神经转位肌皮神经的手术(Oberlin' s method)是最新的方法.本报告应用Oberlin' s手术治疗早期和晚期臂丛神经上中干损伤的初步经验.[方法]5例臂丛神经上中干损伤的患者采用了Oberlin's手术进行伤肢肘关节屈曲功能的恢复治疗.患者平均年龄28岁,随访6～15个月.早期手术2例,分别伤后6个月和8个月手术.晚期病例3例,分别于伤后12～18个月实施手术.术后持续性进行肱二头肌、肘关节屈曲肌力、手内肌握力、尺神经支配区感觉测试.[结果]所有病例都恢复了肘关节的屈曲功能,都有3级以上的肱二头肌肌力恢复.2例早期病例术后1周内出现肱二头肌主动收缩,肘关节主动屈曲功能正常恢复时间平均6个月,平均肌力恢复4+级.3例晚期病例术后平均3个月出现肱二头肌收缩,肘关节主动屈曲功能正常恢复时间平均10个月,平均肌力恢复3+级.3例术后出现尺神经支配区感觉减退,1个月后自动恢复.[结论]Oberlin' s手术是治疗臂丛神经上中干损伤,快速有效恢复肘关节主动屈曲功能的有效方式.     

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.     

联合尺神经束支和臂丛外神经移位治疗臂丛损伤

目的 观察联合尺神经束支和臂丛外神经移位治疗臂丛损伤的临床效果.方法 臂丛损伤6例,其中单纯上干损伤4例;上中干为主,合并下干部分损伤2例.伤后平均2.8个月接受手术.术式包括尺神经部分束支转位至肌皮神经肱二头肌肌支,膈神经或者副神经斜方肌支转位至肩胛上神经,桡神经肱三头肌长头肌支转位修复腋神经肌支.用肱二头肌、岗上肌和三角肌肌力,肩外展和上举角度,尺神经功能损失等指标对手术方式和效果进行评估.结果 6例中5例得到随访,平均随访时间18个月,肱二头肌均在术后3～4个月开始恢复肌力.随访时间18个月以上的4例屈肘M_4~+～M_5;随访时间4个月的1例屈肘M_3~+.其中3例行外展功能重建,单用膈神经修复的病例上臂可上举至180°,外展肌力M_4~+;联合副神经和肱三头肌长头肌支修复的病例上肢可外展90°,肌力M_4~-;单用副神经修复的病例上肢可外展80°,肌力M_3~+.3例手部握持力与术前相同,2例增强.4例手部尺神经供区功能无明显影响,1例小指掌侧皮肤感觉减退,第一骨间背侧肌萎缩.结论 尺神经部分束支转位修复肱二头肌支可以有效的恢复臂丛损伤后屈肘功能;用膈神经修复肩胛上神经可能取得更好的肩外展和上举效果;本组臂丛下干部分损伤的病例受伤均在3个月内,采用此术式同样恢复了肱二头肌功能,未加重原有的手功能障碍.     

Traumatic forearm amputation with avulsions of the ulnar and median nerves from the brachial plexus

A case of a traumatic forearm amputation and associated complete avulsions of the ulnar and median nerves from the brachial plexus due to a crush-traction injury of the distal part of the right forearm is reported. The patient also suffered a traumatic head injury. The injury of the upper limb and the general condition of the patient were so serious that an amputation at the 1/3 middle part of the forearm had to be performed. Received: 12 November 1996     

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.     

Transfer of one fascicle of ulnar nerve to functioning free gracilis muscle transplantation for elbow flexion

Background: In brachial plexus injury, elbow flexion is the first priority in reconstruction. Neglected cases need functioning free muscle transplantation that requires the donor nerve to supply the transplanted muscle. The purpose of this study was to investigate the effects and results of transferring one fascicle of the ulnar nerve to the transplanted gracilis muscle. Methods: One woman and two men with neglected avulsions of the C5,C6 roots of the brachial plexus underwent free gracilis muscle transfer for elbow flexion. One fascicle of the ulnar nerve was used as the donor nerve. Results: The mean period of follow‐up was 33.3 months. The average reinnervation time of gracilis muscle was 3.7 months. At the final examination, the mean strength of elbow flexion was 4.3 kgf. The grip strength, moving two‐point discrimination and the strength of the wrist volar flexion on the affected side was not worse than before surgery in any patient at the last follow‐up examination. Conclusions: A fascicle of the ulnar nerve can be one of the most effective options for functioning free muscle transplantation for elbow flexion.     

Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle 相似文献   

尺神经部分神经束移接肱二头肌运动支术中肌电和疗效观察

目的研究利用尺神经部分神经束移位，治疗臂丛上干根性撕脱伤的临床效果，以及术中应用诱发电位检测供区神经束的经验。方法１９９６年７月～１２月，对６例臂丛上干根性撕脱伤行部分尺神经神经束移接于肌皮神经外侧支手术。术中对尺神经保留部分和切取部分的神经束进行电生理检测。结果尺神经保留部分和切取部分神经束诱发电位的潜伏期和波幅，两者结果均无明显差异。４例术后随访３～７．５个月，肱二头肌肌力恢复到２～３级，供区神经支配区无功能障碍。肌电图检查：神经束移位后的肱二头肌均有新生电位出现。结论采用部分尺神经束移位，治疗臂丛上干根性撕脱伤以恢复屈肘功能，是一个可行的有效的手术方法     

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.     

正中神经部分束支移位与肌皮神经肱二头肌肌支缝合重建屈肘功能

目的评价正中神经部分束支移位与肌皮神经肱二头肌肌支缝合重建屈肘功能的疗效，观察供体神经功能的变化并讨论影响疗效的因素和手术适应证。方法对1995年以来的45例臂丛神经上干根性损伤者，采用正中神经部分束支移位与肌皮神经肱二头肌肌支缝合术。术中切取正中神经后内侧，横截面的1／6～1／5为移位束支，因为来自内侧束的神经纤维多位于后内侧。术后随访12～108个月，患者最终恢复结果按中华医学会手外科学会上肢部分功能评定试用标准评定。结果手术有效率达到86．7％，优良率达60．0％。1／4患者在术后出现供体支配肌肌力和握力减退，术后1～2个月恢复正常。该组中以C5、6根性损伤伴中下干部分损伤、骑摩托车摔伤、41岁以上年龄组的疗效最差。结论正中神经部分束支移位于肌皮神经肱二头肌肌支是治疗臂丛神经上干型根性撕脱伤、重建屈肘功能的一种简单、安全、可靠而有效的手术方法。损伤类型、损伤原因、手术距损伤的间隔时间、患者的年龄及术后的功能锻炼，是影响手术疗效的主要因素。准确判断损伤类型，严格掌握手术适应证是手术成功的关键。     

Pulmonary and biceps function after intercostal and phrenic nerve transfer for brachial plexus injuries

This pseudo-randomized study was performed to compare the pulmonary function and biceps recovery after intercostal (19 cases) and phrenic (17 cases) nerve transfer to the musculocutaneous nerve for brachial plexus injury patients with nerve root avulsions. Pulmonary function was assessed pre-operatively and postoperatively by measuring the forced vital capacity, forced expiratory volume in 1 second, vital capacity, and tidal volume. Motor recovery of biceps was serially recorded. Our results revealed that pulmonary function in the phrenic nerve transfer group was still significantly reduced 1 year after surgery. In the intercostal nerve transfer group, pulmonary function was normal after 3 months. Motor recovery of biceps in the intercostal nerve group was significantly earlier than that in phrenic nerve group. We conclude that pulmonary and biceps functions are better after intercostal nerve transfer than after phrenic nerve transfer in the short term at least.     

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.     

大鼠臂丛神经根性回植后脊髓病理改变和轴突再生

目的 探讨臂丛神经根性撕脱后神经根再植入脊髓的可行性。方法 采用大鼠颈5-7，神经根性撕脱伤实验动物模型，伤后将C5-7，神经根即刻植入脊髓。分别于神经根植入后3周、3个月、6个月取材。应用组织病理活检、免疫组化技术及神经示踪技术，对神经中枢及吻合口下段神经干检查。观察脊髓前角运动神经元和神经元内尼氏体数目和形态的改变；周围神经纤维再生数目、距离，轴索和髓鞘发育情况。结果 臂丛神经根性撕脱伤对动物生长和存活有较大的影响。脊髓前角运动神经元数目在3个月内持续减少，3个月后趋于稳定，6个月时脊髓前角大型运动细胞坏死比率在40％左右，残存的神经元多为受损的神经元，尼氏体减少或消失。脊髓前角运动神经元再生轴突可重新生长入周围神经干，再生神经纤维轴索较细，大部分髓鞘发育不完全，轴突再生距离较短，肌皮神经6个月内无神经纤维再生。结论 臂丛神经根性撕脱伤，神经根回植入脊髓后，脊髓前角运动神经元坏死比率为40％左右，残存神经元多为受损神经元，再生神经纤维表现为动力不足和发育不全，对终末器官功能恢复没有意义。