Nerve transfer to deltoid muscle using the nerve to the long head of the triceps,part II: a report of 7 cases

PURPOSE: This study reports the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps. METHODS: Seven patients with an average age of 25 years with loss of shoulder abduction secondary to upper brachial plexus injuries had nerve transfer using the nerve to the long head of the triceps to the anterior branch(es) of the axillary nerve through the posterior approach. The spinal accessory nerve was used simultaneously for nerve transfer to the suprascapular nerve. The follow-up period ranged from 18 to 28 months (average, 20 mo). RESULTS: All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124 degrees. No notable weakness of elbow extension was observed. CONCLUSIONS: This method is a reliable and effective procedure for deltoid reconstruction in brachial plexus injury (upper-arm type) and should be combined with spinal accessory nerve transfer to the suprascapular nerve to obtain good shoulder abduction.     

Combined nerve transfers for C5 and C6 brachial plexus avulsion injury

PURPOSE: To report the results of combined nerve transfer in C5 and C6 brachial plexus avulsion injury. METHODS: Fifteen patients had nerve transfers: spinal accessory nerve to the suprascapular nerve, a part of the ulnar nerve to the biceps motor branch, and the nerve to the long head of the triceps to the anterior branch of the axillary nerve. Patients were evaluated with regard to elbow flexion, shoulder abduction, and shoulder external rotation. RESULTS: All patients had recovered full elbow flexion: 13 scored M4 and 2 scored M3. Thirteen of the 15 patients obtained good results. The weight the patients could lift ranged from 0 to 7 kg. All patients had recovery of the deltoid function: 13 scored M4 and 2 scored M3. All 15 patients achieved useful functional recovery. Ten patients experienced excellent recoveries and 5 were classified as having good results. The mean shoulder abduction was 115 degrees . Shoulder external rotation strength was scored as M4 in 9 patients, M3 in 4 patients, and M2 in 2 patients. The range of motion of external rotation that was measured from full internal rotation averaged 97 degrees . No clinical donor nerve deficits were observed. CONCLUSIONS: We recommend combined nerve transfers for C5 and C6 avulsion root injuries. These nerve transfers have the advantage of a quick recovery time as a result of the short regeneration distance without nerve graft. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients

Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating injuries. Although secondary procedures such as tendon and muscle transfers have been used, they never achieve a functional recovery comparable to that following successful reinnervation of the supraspinatus, deltoid, teres minor, and infraspinatus muscles. Early restoration of suprascapular and axillary nerve function through timely brachial plexus reconstruction offers a good opportunity to restore shoulder-joint stability, adequate shoulder abduction, and external rotation function. Overall, in our series, 79% of patients achieved good and excellent shoulder abduction (muscle grade, +3 or more), and 55% of patients achieved good or excellent shoulder external rotation after reinnervation of the suprascapular nerve. The best results were seen when direct neurotization of the suprascapular nerve from the distal spinal accessory nerve or neurotization by the C5 root was carried out. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction and external rotation function.     

Contralateral C7 nerve root transfer to neurotize the upper trunk via a modified prespinal route in repair of brachial plexus avulsion injury

Purpose: In this report, we present our experience on the repair of brachial plexus root avulsion injuries with the use of contralateral C7 nerve root transfers with nerve grafting through a modified prespinal route. Methods: The outcomes of the contralateral C7 nerve root transfer to neurotize the upper trunk and C5/C6 nerve roots of the total or near total brachial plexus nerve root avulsion injury in a series of 41 patients were evaluated. The contralateral C7 nerve root that was dissected to the distal end of the divisions, along with the sural nerve graft, were placed underneath the anterior scalene and longus colli muscles, and then passed through the retro‐esophageal space to neurotize the recipient nerve. The mean length of the dissected contralateral C7 nerve root was 6.5 ± 0.7 cm, and the mean length of sural nerve graft was 6.8 ± 1.9 cm. The suprascapular nerve was neurotized additionally by the phrenic nerve or the terminal motor branch of accessory nerve in some patients. Results: The mean length of the follow‐up was 47.2 ± 14.5 months. The muscle strength was graded M4 or M3 for the biceps muscle in 85.4% of patients, for the deltoid muscle in 82.9% of patients, and for the upper parts of pectoral major in 92.7% of patients. The functional recovery of shoulder abduction in the patients with the additional suprascapular nerve neurotization was remarkably improved. Conclusions: The modified prespinal route could significantly reduced the length of nerve graft in the contralateral C7 nerve root transfer to the injured upper trunk in brachial plexus root avulsion injury, and it may improve the functional outcomes, which deserves further investigations. © 2011 Wiley Periodicals, Inc. Microsurgery, 2012.     

手术治疗创伤致神经源性单纯肩外展功能障碍

 目的 探讨手术治疗肩部创伤致肩胛上神经与腋神经同时损伤的疗效。方法 回顾性分析2003年7月至2011年9月,手术治疗13例男性肩部创伤后诊断为肩胛上神经与腋神经同时损伤的患者资料,年龄8~59岁,平均28 岁;受伤至手术时间为2~7个月,平均3.7个月。其中肩胛颈和锁骨同时骨折2例,浮肩损伤3例,肱骨颈及关节盂骨折1例,锁骨骨折3例,肩峰骨折1例,肩胛骨骨折2例,寰枢椎骨折1例。13例临床检查均示单纯肩外展、外旋功能完全丧失,三角肌及冈上、下肌肌力均为0级。电生理检查示腋神经、肩胛上神经完全失神经支配。肩胛上神经断裂10例,其中6例通过1股腓肠神经移植修复,1例通过1股颈丛浅支移植修复,3例因远端撕脱而放弃神经修复;另3例肩胛上神经仅进行松解。腋神经断裂12例,其中10例采用2~3股腓肠神经移植修复,2例采用正中神经束支移位修复;另1例腋神经于四边孔处进行松解。13例患者中,10例患者的肩胛上神经及腋神经同时断裂。结果 13例患者随访时间36~134个月,平均85个月;7例肩关节上举恢复正常达180°,该7例的三角肌力均为4级,肩外旋40°~70°,平均56°;5例肩外展达30°~50°,平均38°;该5例肩外旋为-40°~30°,平均10°,三角肌肌力4级1例,3级2例,2级2例;另1例无恢复。结论 对于肩部创伤后出现的单纯肩关节外展、外旋功能完全丧失,应考虑肩胛上神经与腋神经同时损伤的可能。此种类型的神经损伤修复后的效果满意,应尽早进行神经移植修复。     

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.     

Evaluation of suprascapular nerve neurotization after nerve graft or transfer in the treatment of brachial plexus traction lesions

OBJECT: The aim of this retrospective study was to evaluate the restoration of shoulder function by means of suprascapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a severe brachial plexus traction injury. The primary goal of brachial plexus reconstructive surgery was to restore biceps muscle function and, secondarily, to reanimate shoulder function. METHODS: Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve was performed in 18 patients. Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four patients (8%) infraspinatus muscle power was MRC Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 +/- 17 degrees (standard deviation [SD]; median 45 degrees) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 +/- 24 degrees (SD; median 53 degrees). In only three patients (6%) were both functions regained. CONCLUSIONS: The reanimation of shoulder function in patients with proximal C-5 and C-6 brachial plexus traction injuries following suprascapular nerve neurotization is disappointingly low.     

健侧C7 神经根经椎体前移位修复臂丛上干损伤的中期临床随访

目的 观察健侧C7 神经根经椎体前通路移位修复臂丛上干损伤重建肩外展、屈肘功能的中期效果.方法 健侧C7 神经根经椎体前通路移位修复臂丛上干损伤患者15例,男14例,女1例;年龄15～43岁,平均30岁.全臂丛撕脱伤7例,上、中干撕脱伴下干不全损伤6例,上、中干损伤2例.健侧C7 神经根经椎体前通路移位到患侧臂丛上干的距离平均(7.6±1.7)cm,8例同时行副神经或膈神经移位单独修复肩胛上神经.结果 随访36～63个月,平均50个月.健侧上肢用力内收时,12例患者的肱二头肌、三角肌、胸大肌锁骨部、冈上肌肌力(8例来自副神经或膈神经的支配)均达到4级,大脑皮层运动支配中枢发生临床转化;另3例肌力为3级或以下,尚未发生大脑皮层运动支配中枢的临床转化.健侧上肢用力内收时,8例肩胛上神经单独修复者的肩外展角度平均78.0°,另7例平均43.1..结论 健侧C7 神经根经椎体前通路移位可用于修复臂丛上千损伤,桥接神经的距离短,重建肩外展及屈肘功能的效果良好,大脑皮层运动支配中枢可发生临床转化.     

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     

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.     

Repair of isolated axillary nerve lesions after infraclavicular brachial plexus injuries: case reports

Stretch injuries of the infraclavicular brachial plexus have a much better prognosis for spontaneous recovery than do their supraclavicular counterparts. We present three patients with stretch injuries of the infraclavicular brachial plexus who had spontaneous restoration of function in all muscles except the deltoid. Decreased shoulder abduction was a serious handicap to these individuals. At surgical exploration, each patient had an isolated, complete axillary nerve disruption at the quadrilateral space. Deltoid muscle function was restored in all three patients by repair of the axillary nerve with sural nerve grafts across the quadrilateral space.     

Clinical results of contralateral C7 root neurotization to the median nerve in brachial plexus injuries with total root avulsions

This prospective study was carried out to assess motor and sensory recovery after contralateral C7 root to median nerve neurotization in brachial plexus injuries with total root avulsions. The survey was carried out from 1993 to 1995 and the patients were followed up for at least 3 years. There were 96 male patients with ages ranging from 13 to 48 years. All had a unilateral brachial plexus injury with avulsion of all roots. This was confirmed by clinical assessment and exploration. The anterior part of the contralateral C7 root was used for neurotization via a reversed pedicular ulnar nerve graft and the proximal end of the graft was connected to the median nerve. Furthermore, phrenic nerve to suprascapular nerve and spinal accessory nerve (via a sural nerve graft) to musculocutaneous nerve neurotizations were also carried out to obtain shoulder abduction and elbow flexion. At the 3 year follow-up, most patients had encouraging recovery of sensory function in the hand but motor function of the forearm and hand muscles was rather poor. Acceptable motor function was found in only 50 to 60% of the patients who were younger than 18 years.     

Posterior Approach for Double Nerve Transfer for Restoration of Shoulder Function in Upper Brachial Plexus Palsy

Restoration of shoulder function is one of the most critical goals of treatment of brachial plexus injuries. Primary repair or nerve grafting of avulsion injuries of the upper brachial plexus in adults often leads to poor recovery. Nerve transfers have provided an alternative treatment with great potential for improved return of function. Many different nerves have been utilized as donor nerves for transfer to the suprascapular nerve and axillary nerve for return of shoulder function with variable results. As our knowledge of shoulder neuromuscular anatomy and physiology improves and our experience with nerve transfers increases, so evolve the specific transfer procedures. This article presents a technique and rationale for reconstructing shoulder function by transferring the distal spinal accessory nerve to the suprascapular nerve and the nerve branch to the medial head of the triceps to the axillary nerve, both through a posterior approach.     

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。     

二期多组神经移位治疗臂丛神经根性撕脱伤的临床应用和疗效

目的 分析治疗臂丛神经根性撕脱伤的二期手术方法及其效果。方法 2001年8月～2003年4月8例全臂丛神经根性撕脱伤患者，年龄18～38岁。平均伤后6个月内，均应用以下术式治疗。手术步骤：一期手术，膈神经移位至臂丛上干前股，副神经移位至肩胛上神经；健侧C7神经移位至患侧尺神经；二期手术，第4、5、6、7肋间神经移位至桡神经和胸背神经，健侧C7神经经尺神经移位至正中神经。结果 术后8例均获随访，时间为二期术后l3～25个月，平均21个月。所有患者均有不同程度恢复，相应靶肌肉肌力恢复大于或等于M3为有效恢复，肌皮神经有效恢复6例，恢复率为75．0％；肩胛上神经有效恢复3例，恢复率为37．5％；桡神经有效恢复3例，恢复率为37．5％；胸背神经有效恢复6例，恢复率为75．0％；正中神经有效恢复5例，恢复率为62．5％。感觉恢复情况：正中神经感觉4例为S3，3例为S2，1例为S1。结论 二期多组神经移位安全有效，对部分早期臂丛神经损伤并要求缩短手术次数的患者，是一种可选择的方法。     

Restoration of shoulder abduction in brachial plexus injury with phrenic nerve transfer

BACKGROUND: Shoulder abduction is one of the most essential functions in reconstruction of the brachial plexus following injury. In the literature there are few reports on phrenic nerve transfer, especially in relation to restoration of shoulder function. The purpose of the present study was to evaluate the clinical effectiveness and safety of phrenic nerve transfer. METHODS: A study was made of 10 cases of phrenic nerve transfer to the suprascapular nerve. RESULTS: The average shoulder abduction was 41 degrees (range: 20-60 degrees). The average degree of shoulder abduction in patients with C5 or C6 root avulsions was slightly more than that in the patients with total root avulsions. There was no clinically significant respiratory insufficiency in any patient. CONCLUSIONS: Phrenic nerve transfer to the suprascapular nerve is an effective, reliable and safe method of shoulder abduction restoration in brachial plexus injury.     

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.     

Functional Evaluation of Levator Scapulae Tendon to Supraspinatus in Adult Brachial Plexus Injuries

Introduction  Brachial plexus injuries are severe life-altering injuries. The surgical method to restore shoulder abduction in adult upper brachial plexus injuries involves the usage of nerve grafts and nerve transfers targeting the suprascapular and/or the axillary nerve. When the primary nerve surgery has been unsuccessful or recovery has been incomplete or with a late presentation, muscle transfer procedures are needed to provide or improve shoulder abduction. Levator scapulae to supraspinatus is a transfer to improve shoulder abduction in posttraumatic brachial plexus injuries. Material and Methods  The study included 13 patients with the age ranging from 17 to 47 years with a mean age of 30 years. All these patients had preop shoulder abduction of Medical Research Council (MRC) grade ≤3. All had a minimum of MRC grade 4 of active elbow flexion. Eleven patients had primary surgery. Only patients with a minimum of 1 year postoperative follow-up were included. All 13 patients underwent levator scapulae transfer only. Results  All patients had a stable shoulder postoperatively. The average increase in active shoulder abduction was from 6.15°(median: 0°) preoperatively to 61.92°(median: 60°), with an average gain in shoulder abduction of 49.61°(median: 50°). Conclusions  Transfer of levator scapulae tendon to the supraspinatus is an option to improve shoulder abduction in posttraumatic brachial plexus. In conditions where supraspinatus alone is not functioning, levator scapulae is the best available transfer, considering its strength and maintaining the form of the shoulder unlike trapezius transfer. In patients with previous surgery where supraspinatus has recovered partially but not functionally significant, this tendon transfer can be considered for the augmentation of the existing shoulder abduction.     

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.     

Triceps nerve to deltoid nerve transfer after an unsatisfactory intra-plexus neurotization of the posterior division of the upper trunk

IntroductionOur literature review did not reveal any study on the results of triceps to deltoid nerve transfer done as a secondary procedure after an unsatisfactory primary intraplexus neurotization of the posterior division of the upper trunk.Presentation of casesWe report on three adults with C5-C6 brachial plexus injury who had an unsatisfactory deltoid function following primary intraplexus neurotization. Patients presented to our clinic late (14–16 months after injury). All patients had poor shoulder abduction (<40°) despite the presence of visible and palpable deltoid contractions. A triceps to deltoid nerve transfer resulted in an excellent shoulder abduction (> 150°) in all patients.DiscussionThe primary surgery in our patients acted as a “baby-sitter” procedure; explaining the good results of the late secondary distal nerve transfer.ConclusionGood results may be obtained from a late distal nerve transfer for the deltoid muscle as long as there is partial innervation of the muscle.