Nerve transfers for brachial plexus reconstruction

Brachial plexus injuries result in devastating loss of function for patients and present incredible challenges for peripheral nerve surgeons. Recently, nerve transfers have produced superior results compared with traditional interposition nerve grafts for brachial plexus reconstruction. The authors present a review of current surgical options for treatment of partial and complete adult brachial plexus injuries using nerve transfers.     

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).     

Phrenic nerve transfer for brachial plexus motor neurotization

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

Nerve transfers in brachial plexus palsies

It has been many years now since the introduction of nerve transfers for repair of traumatic brachial plexus lesions and more recently, we have seen its application in the field of obstetric brachial plexus palsy. These nerve transfers do not represent an alternative to anatomical repair by means of nerve grafting, but represent an additional possibility to increase the reconstructive options and improve the final results. This pushes the surgeon to decide: which function is to be restored by nerve grafting, which one by nerve transfer? What is the more reliable procedure? Does the age of the patient, the delay after the accident, or the type of accident influence this choice? If we add in the possibilities of palliative treatment, one can state that many therapeutic options are available today for brachial plexus reconstruction, and that no real consensus does exist. But some tendencies, some trends are apparent.     

Muscle transfers in brachial plexus lesions

The concept of reconstruction to regain lost function after brachial plexus lesions has to be as broad and complex as possible. We have been exploring wider and more novel clinical concepts at the Clinic of Plastic, Hand, and Reconstructive Surgery at the Medical School of Hannover. Our ideas are supported by experience in 160 patients. We have attempted to combine the use of a vascularized nerve graft and a microvascularly-transferred autologous muscle. Patients undergoing the procedures have included those with late complete root avulsions and no functional return, as well as previously operated cases with poor recovery of biceps, wrist, and forearm function. The surgery is divided into two stages. In the first stage, the ulnar nerve is prepared as a vascularized nerve graft and is sutured to intercostal nerves 3 to 5 or 6. In stage 2, when the Tinel sign reaches the distal ends of the ulnar nerve graft (about six to eight months later), the latissimus dorsi muscle is harvested. The muscle is then placed as far distally as possible in the forearm and sutured to the deep finger flexors and flexor pollicis longus. Proximally, the insertion is performed similarly to Steindler's method. The vessels are connected to the brachial artery and vein and the thoracodorsal nerve is sutured to the graft. This method provides flexion of both the fingers and the elbow.     

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 outcome of nerve transfers for traumatic global brachial plexus avulsion

BackgroundThe treatment of global brachial plexus avulsion is a demanding field of hand and upper extremity surgery. The recent development of functional and quality-of-life (QOL) assessment tools has improved quantifying these functional outcomes after surgery.ObjectiveWe sought to combine Medical Research Council (MRC) grading with the Disability of the Arm, Shoulder, and Hand (DASH) questionnaires and Numerical Rating Scale (NRS) for pain to evaluate the functional outcome of patients who suffered complete brachial plexus avulsion before and after nerve transfers.MethodsThe author carried out a retrospective review of 37 patients with global avulsion of the brachial plexus between 2000 and 2007. All of them underwent nerve transfers in Hua Shan Hospital in Shanghai. They were followed up for over 3 years for physical examination and responding to the questionnaires of DASH, NRS, as well as the satisfaction with the surgery.ResultsThe mean time to surgery was less than 6 months and the mean follow-up period was 4.59 years (range: 3–9 years). The effective motor recovery rate was 54%, 86%, 46% and 43%, respectively, in supraspinatus, biceps, triceps and finger flexor. Patients who underwent nerve transfers scored consistently better on the DASH score and NRS score than those before surgery. There was also a significant correlation between the change in NRS scores and patient satisfaction.ConclusionThis study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients’ self-assessments. Neurolysis after neurotisations correlated positively with functional outcomes.     

Selective motor hyperreinnervation by using contralateral C-7 motor rootlets in the reconstruction of an avulsion injury of the brachial plexus. Case report.

Brachial plexus avulsion injuries are a clinical challenge. In recent experimental studies the authors have demonstrated the high degree of muscle reinnervation attained when a C-4 motor rootlet was directly connected to the musculocutaneous nerve. This degree of reinnervation was attributed to the good chance that a muscle fiber can be reinnervated by a motor fiber when the number of regenerating motor neurons is increased and when competitive sensory fibers are excluded from the process. The authors present the first clinical case in which this phenomenon has been observed. This 26-year-old man, who was involved in an automobile accident, presented with an upper brachial plexus avulsion, for which he underwent operation 4 months later. The axillary and suprascapular nerves were directly surgically connected to the motor rootlets of the C-7 contralateral root by using two cables of sural nerve graft. Two years postsurgery, the patient was able to perform shoulder abduction of 120 degrees and hold an 800-g weight at 90 degrees. These results are encouraging, and in selected patients motor rootlet transfer might prove to be a useful surgical strategy.     

Tendon transfers for brachial plexus injury

Brachial plexus injuries result in severe functional deficits in the upper limb. The authors review a group of 74 patients with brachial plexus injuries who underwent 160 tendon transfer operations, as well as 94 additional procedures, in an attempt to augment lost function. Following evaluation of functional recovery, 58 percent of the patients were rated Good, 34 percent Improved, and 8 percent Unimproved. The authors conclude that significant benefit can be obtained by peripheral reconstruction and tendon transfers in patients with brachial plexus injuries.     

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.     

神经移植移位术治疗产瘫的早期疗效分析

目的探讨臂丛神经瘤切除后,神经移植或移位术对产瘫患儿上肢功能的影响及变化规律,为该手术在临床推广提供依据。方法2 0 0 1年3月至2 0 0 2年4月,对49例早期产瘫患儿,采用臂丛神经瘤切除、神经移植或移位术修复臂丛神经。术后经1、3、12个月随访肩外展、屈肘、伸腕和伸掌指关节功能,用配对t检验比较手术前后患肢功能的差异。结果结合术前体检、术中各神经根探查及电生理检测结果,手术探查发现C5、6神经根以椎孔外断裂为主;C7神经根多为根性撕脱;C8、T1神经根常为轻度损伤(SunderlandⅡ度以下)或根性撕脱。术后1个月原已部分恢复的肩外展、屈肘、伸腕和伸掌指关节动作均丧失;术后3个月肩外展功能已优于术前,屈肘、伸腕和伸掌指关节功能恢复到术前水平;术后1年肩外展、屈肘、伸腕和伸掌指关节功能明显优于术前(P <0 .0 1)。结论对有早期手术探查指征的产瘫患儿,在切除创伤性神经瘤的同时修复臂丛神经,术后不会导致肢体原有功能的不可逆损害。     

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.