副神经移位恢复高位颈髓横断伤大鼠膈肌运动功能的初步研究

目的：探讨副神经移位膈神经恢复膈肌运动功能的可行性。方法：成年雄性SD大鼠100只随机分成A、B2组。经颈前路显露两侧膈神经干，于C6水平切断。A组原位缝接；B组游离副神经，在其主干进入斜方肌前切断，并与膈神经干缝接。术前：术后5min及第1、2、4、6、8个月观察膈肌的位移，然后于C3－4水平横断脊髓了解膈肌的位移变化。比较各时间点2组膈肌位移的恢复率。结果：高位颈髓横断伤前2组膈肌位移恢复率无显著性差异，而高位颈髓横断伤后3组膈肌位移恢复率明显优于A组。结论：副神经移位膈神经能有效地恢复高位颈髓横断伤大鼠的膈肌运动功能。     

膈神经端侧吻合移位治疗肌皮神经损伤的实验研究

目的 研究膈神经端侧吻合移位至肌皮神经治疗臂丛神经撕脱伤的可行性.方法 取雄性SD大鼠51只,随机分成4组:A组,单侧全臂丛神经撕脱组;B组,膈神经端端吻合组;C组,膈神经端侧吻合组;D组,膈神经螺旋状端侧吻合组(B、C、D组膈神经均移植2.0 cm腓肠神经至肌皮神经).并于术后进行肢体功能、组织学和神经电生理检测.另取绿色荧光蛋白(green fluorescent protein,GFP)转基因F344大鼠9只,通过荧光显微镜观察膈神经轴突再生情况.方果 各实验组术后手术侧肢体功能逐渐恢复,术后神经电生理和组织学检测表明,术后3个月,C、D组左侧肱二头肌肌张力恢复率和肌湿重恢复率,分别为B组的76.4%和86.3%、85.6%和87.7%,即端侧吻合组肱二头肌功能达到端端吻合组的80%以上,同时保留了膈肌的功能.荧光显微镜观察发现膈神经轴突通过端侧吻合口长入移植神经.方论 膈神经端侧吻合治疗臂丛神经损伤的手术方法是有效、可行的.     

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.     

Surgical management of trapezius palsy

BACKGROUND: Injury to the spinal accessory nerve in the posterior cervical triangle leads to paralysis of the trapezius muscle. The aim of this study was to determine the indications for nerve repair or reconstructive surgery according to the etiology, the duration of the preoperative delay, and specific patient characteristics. METHODS: Of twenty-seven patients with a trapezius palsy, twenty were treated with neurolysis or surgical repair (direct or with a graft) of the spinal accessory nerve and seven were treated with the Eden-Lange muscle transfer procedure. Lymph node biopsy was the main cause of the nerve injury. The nerve repairs were performed at an average of seven months after the injury, and the reconstructive procedures were done at an average of twenty-eight months. Nerve repair was performed for iatrogenic injuries of the spinal accessory nerve, within twenty months after the onset of symptoms, and in one patient with spontaneous palsy. Reconstructive surgery was performed for cases of trapezius palsy secondary to radical neck dissection, for spontaneous palsies, and after failure of nerve repair or neurolysis. The mean follow-up period was thirty-five months. The functional outcome was assessed clinically on the basis of active shoulder abduction, pain, strength of the trapezius on manual muscle-testing, and level of subjective patient satisfaction. RESULTS: The results were good or excellent in sixteen of the twenty patients treated with nerve repair and in four of the seven patients treated with the Eden-Lange procedure. Poor results were seen in older patients and in patients with a previous radical neck dissection. CONCLUSIONS: Good results can be expected from a repair of the spinal accessory nerve if it is performed within twenty months after the injury, as the nerve is basically a purely motor nerve and the distance from the injury to the motor end plates is short. Muscle transfer should be performed in patients with spontaneous trapezius palsy, when previous nerve surgery has failed, or when the time from the injury to treatment is over twenty months. Treatment is less likely to succeed when the patient is older than fifty years of age or the palsy was due to a radical neck dissection, penetrating injury, or spontaneous palsy.     

Surgical anatomy of spinal accessory nerve: is trapezius functional deficit inevitable after division of the nerve?

The course of spinal accessory nerve in the posterior triangle, the innervation of the sternocleidomastoid and trapezius muscles and the contributions from the cervical plexus were studied in 20 cadaveric dissections. The nerve was most vulnerable to iatrogenic injuries after leaving the sternocleidomastoid. Direct innervation of trapezius by cervical plexus branches was noted in five dissections, whereas connections between the cervical plexus and the spinal accessory nerve were observed in 19 dissections. These were usually under the sternocleidomastoid (proximal to the level of division of the nerve in nerve transfer procedures). Although the contribution from the cervical plexus to trapezius innervation is considered minimal, trapezius function can be protected in neurotization procedures by transecting the spinal accessory nerve distal to its branches to the upper position of trapezius.     

颈7神经根后股与副神经移位吻合重建斜方肌功能

目的探讨一种根治性颈淋巴清扫术（radical neck dissection，RND）中采用神经移位吻合改善术后肩功能的方法。方法1999年3月～2001年2月，10例需行RND的患者，行RND时保留远颅端至斜方肌前缘的副神经，长度〉3cm，待RND完成后，解削分离出C7神经，并将其后股切断，长度3～5cm，在无张力下行两神经端端吻合。患者在术前和术后1、6及12个月行临床的斜方肌功能客观评价及肌电检测。结果经c，神经根后股与副神经移位吻合后，各部肌电恢复率1、6及12个月分别为上部9．8％、68．9％、73．5％；中部4．7％、73．6％、69．4％；下部6．2％、70．5％、70．3％；7例患者上臂外展超过90。，上肢平均最大外展角度超过95。，肌萎缩较轻，均为1～2级，肩外展受限2级7例．3级3例。结论RND中采用C7神经根后股与副神经移位吻合能较好地重建斜方肌功能。供、受区位于同一术区内，仅有一个吻合口，减少手术创伤。C7神经根后股的切断对手臂运动及感觉功能无影响。     

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).     

Pulmonary function after complete unilateral phrenic nerve transection

OBJECT: The status of pulmonary function following phrenic nerve transfer surgery is still largely unknown because of the high degree of variability in the accessory phrenic nerve that may be involved. In the present study, pulmonary functions were assessed in patients before and after full-length phrenic nerve transfer surgery, in whom the phrenic nerve was severed at a location just before its entry into the diaphragm. METHODS: Fifteen patients (average age 27.4 years) with complete brachial plexus palsy underwent full-length phrenic nerve transfer. The phrenic nerve was harvested from the thoracic cavity by means of video-assisted thoracic surgery and then transferred to the musculocutaneous nerve. Postoperative pulmonary functions were retrospectively analyzed. Patients underwent follow-up evaluation for 42 to 48 months; four patients were eventually lost to follow up. Although no patient experienced pulmonary problems following the surgery, all sustained varying degrees of diaphragmatic paralysis and elevation (for 1-1.5 intercostal spaces) on the surgically treated side as seen on chest x-ray films. Pulmonary functional parameters, including vital capacity, vital capacity in percentage of predicted values, residual volume, total lung capacity, forced vital capacity, and forced expiratory volume in 1 second, recovered to preoperative levels by 1 year postsurgery. In contrast, the postoperative maximal inspiratory pressure value was significantly decreased compared with the predicted values (average decrease approximately 20%) in all of the patients, even at 4 years after the surgery. CONCLUSIONS: In young patients with healthy lung function, unilateral phrenic nerve transection surgery can cause unilateral diaphragmatic paralysis and reduce the inspiration muscle force; however, most pulmonary function parameters gradually recover to preoperative levels within 1 year.     

Phrenic nerve end-to-side neurotization in treating brachial plexus avulsion: an experimental study in rats

The aim of this study was to extend the clinical application of phrenic nerve neurotization in treating brachial plexus avulsion injury, reducing the possible damage on the diaphragm function. Fifty-one male Sprague-Dawley rats and 9 transgenic rats were used in this study. Evaluations including behavioral observation, histology, and electrophysiology study were performed postoperatively. The functional recovery of rats with the end-to-side neurorrhaphy reached 80% of those with end-to-end neurorrhaphy, and the function of diaphragm was preserved. The fluorescence study revealed abundant collateral sprouting of the phrenic nerve axons through the coaptation site in all the experimental groups. The study showed that the end-to-side neurorrhaphy in a helicoid manner and the standard end-to-side neurorrhaphy were effective in the treatment of brachial plexus root avulsion injury with little harm to the function of diaphragm. This will extend the clinical application of phrenic nerve neurotization in treating brachial plexus avulsion injury.     

High cervical lateral spinal cord injury results in long-term ipsilateral hemidiaphragm paralysis

Although axon regeneration is limited in the central nervous system, partial lesions of the spinal cord induce neuroplasticity processes that can lead to spontaneous functional improvement. To determine whether such compensatory mechanisms occur in the respiratory system, we analyzed the incidence of partial injury of the cervical spinal cord on diaphragm activity in adult rats. We show that a section of the lateral area of the C2 cervical spinal cord induces complete phrenic nerve inactivation and ipsilateral hemidiaphragm paralysis, whereas medial or dorsolateral sections had only a moderate effect on respiratory activity. In the case of lateral hemisection, activity of the ipsilateral phrenic nerve was partially restored after a lapse of 3 months. No spontaneous diaphragm recovery was observed, however, even after a lapse of several months in the case of hemisection or lateral section. Ipsilateral hemidiaphragm activity could however be restored after transection of the contralateral phrenic nerve, by activation of the "crossed phrenic phenomenon" (involving activation of previously latent respiratory contralateral pathways crossing the midline). These data suggest that the respiratory system develops important long-term plasticity processes at the level of phrenic motoneuron innervation. However, they do not by themselves allow substantial diaphragm recovery, underscoring the continued need for developing repair strategies. These studies also validates the use of the respiratory system as a model to evaluate the functional incidence of repair strategies not only after hemisection but also after more limited sectioning restricted to the lateral side of the cervical cord.     

Bilateral diaphragmatic plication for an adult patient

Bilateral phrenic nerve paralysis is a very rare complication in open-heart surgery. An 65-year-old woman sustained respiratory distress after coronary artery bypass grafting because of bilateral phrenic nerve paralysis. Bilateral diaphragmatic plication was performed on the 43rd postoperative day. She successfully weaned from ventilator support without difficulty a few days after plication. We believe that surgical plication of the diaphragm is a safe and effective technique for a distressed adult patient with paralyzed diaphragm.     

后入路副神经移位至肩胛上神经的应用解剖

目的 对斜方肌内的神经支配进行解剖学观察,为寻找副神经移位到肩胛上神经的最佳移位点和移位方式提供解剖依据.方法 选用成人尸体标本10具20侧.观察副神经在斜方肌内的行径及分支.并取不同水平副神经、肩胛上神经横断面制病理切片,计数各神经断面的神经纤维数,进行比较.结果 副神经在锁骨上2～3 cm进入斜方肌内,在肩胛冈中点前上方3～4 cm处,有来自颈丛的交通支加入后形成终末支.副神经的神经纤维计数:入斜方肌处(A点)为(1245±46)条,颈丛的交通支汇入前(B点)为(830±36)条,汇入后(C点)为(1074±38)条.结论 (1)副神经在与颈丛交通支合干后H-G段内的各断点,是副神经的最佳移位点.(2)后进路副神经移位术不影响斜方肌上部神经支配,充分利用了颈丛交通支,且缩短了神经再生距离,值得推广.     

Long-term results of spinal accessory nerve-facial nerve anastomosis.

A number of methods have been developed to reduce the cosmetic and functional disability resulting from facial nerve loss. It has often been suggested that the major trunk of the spinal accessory nerve should not be sacrificed for providing dynamic facial function because of shoulder disability and pain. A review of Mayo Clinic records has revealed that, between the years of 1975 and 1983, 25 patients underwent spinal accessory nerve-facial nerve anastomosis using the major division (branch to the trapezius muscle) of the spinal accessory nerve. There were 11 males and 14 females, ranging in age from 16 to 60 years (mean 41 years). The interval between facial nerve loss and anastomosis was 1 week to 34 months (mean 4.62 months). The duration of follow-up study ranged from 7 to 15 years (mean 10.8 years). Twenty patients had no complaints or symptoms related to their shoulder or arm at the time of this review and no patient had significant shoulder morbidity. The facial function achieved was "minimal" in five cases, "moderate" in six, and good to excellent in 14. Most patients appeared to benefit significantly from the spinal accessory nerve-facial nerve anastomosis. The morbidity of the procedure seemed quite minimal even in the young and active. The authors continue to believe that the spinal accessory nerve-facial nerve anastomosis, even when using the major trunk of the spinal accessory nerve, is a very useful and beneficial procedure.     

Phrenic and diaphragm function after coronary artery bypass grafting.

We studied respiratory mechanics and phrenic nerve and diaphragm function in 12 patients on the day before and eight to 13 days after coronary artery bypass grafting. The average vital capacity, functional residual capacity, and total lung capacity decreased by 20.5%, 9.5%, and 14.7% respectively after operation. Eleven patients showed less negative maximum inspiratory mouth pressures at any given lung volume after surgery and the magnitude of the change correlated with the reduction in total lung capacity. In 11 of the 12 patients the conduction times of the right and left phrenic nerves did not change substantially after operation and the ratio of inspiratory electrical activity (Edi) of left and right hemidiaphragms was similar before and after the procedure. One patient, however, showed a considerable increase in left phrenic nerve conduction time and a reduction in the left to right Edi ratio postoperatively. In three patients diaphragm function was also assessed by changes in transdiaphragmatic pressure during supramaximal phrenic nerve stimulation and voluntary increase in inspired volume; in none of the three patients did the transdiaphragmatic pressure swings show any significant change in the postoperative period. These data indicate that phrenic nerve paralysis only occasionally accounts for the postoperative loss of lung volume after coronary artery bypass grafting surgery. The mechanism of these abnormalities therefore remains to be determined.     

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.     

Spinal accessory nerve injury

Injury to the spinal accessory nerve can lead to dysfunction of the trapezius. The trapezius is a major scapular stabilizer and is composed of three functional components. It contributes to scapulothoracic rhythm by elevating, rotating, and retracting the scapula. The superficial course of the spinal accessory nerve in the posterior cervical triangle makes it susceptible to injury. Iatrogenic injury to the nerve after a surgical procedure is one of the most common causes of trapezius palsy. Dysfunction of the trapezius can be a painful and disabling condition. The shoulder droops as the scapula is translated laterally and rotated downward. Patients present with an asymmetric neckline, a drooping shoulder, winging of the scapula, and weakness of forward elevation. Evaluation should include a complete electrodiagnostic examination. If diagnosed within 1 year of the injury, microsurgical reconstruction of the nerve should be considered. Conservative treatment of chronic trapezius paralysis is appropriate for older patients who are sendentary. Active and healthy patients in whom 1 year of conservative treatment has failed are candidates for surgical reconstruction. Studies have shown the Eden-Lange procedure, in which the insertions of the levator scapulae, rhomboideus minor, and rhomboideus major muscles are transferred, relieves pain, corrects deformity, and improves function in patients with irreparable injury to the spinal accessory nerve.     

Delayed diaphragm recovery in 12 patients after high cervical spinal cord injury. A retrospective review of the diaphragm status of 107 patients ventilated after acute spinal cord injury

STUDY DESIGN: The functional outcome of the diaphragm after acute spinal cord injury was reviewed over a 16 year period for 107 patients who had required assisted ventilation in the acute phase. OBJECTIVES: To quantify the incidence of recovery of diaphragm function which occurred beyond the period of acute oedema; to produce a time-related profile of this as a guide to clinicians considering phrenic nerve pacing; and to assess the value of phrenic nerve testing in predicting recovery. SETTING: The Southport Regional Spinal Injuries Centre, Southport, England. METHODS: Bilateral phrenic nerve and diaphragm integrity was assessed clinically, by spirometry, and by fluoroscopy without and with phrenic nerve stimulation. RESULTS: Thirty-one per cent of all the ventilated patients (33 cases), with a level of injury between C1 and C4 (Scale A in ASIA Impairment Scale), had diaphragmatic paralysis at the time of respiratory failure. The subsequent diaphragm recovery which appeared in seven of these patients, between 40 and 393 days (mean 143), permitted weaning from ventilatory support at 93 to 430 days (mean 246) after the acute injury, with a vital capacity of over 15 ml kg(-1) at that stage. The diaphragm recovery in a further five patients, whose vital capacity remained below 10 ml kg(-1) and who could not be fully weaned, occurred significantly later, between 84 and 569 days (mean 290), P=0.053. Negative phrenic nerve tests were followed by weaning at a later interval in several cases. By contrast, one patient with an early positive phrenic stimulation test and subsequent diaphragm activity could not be weaned from the ventilator. CONCLUSION: Twenty-one per cent of the patients with initial diaphragm paralysis were ultimately able to breathe independently after 4 and 14 months, whilst a further 15% had some diaphragm recovery. Phrenic nerve testing should be repeated at 3 monthly intervals for the first year after high tetraplegia.     

Accessory nerve neurotization in infants with brachial plexus birth palsy

We report the surgical results of 13 accessory nerve neurotizations in brachial plexus birth palsy. The mean age at operation was 5.9 months. The accessory nerve was transferred to three C5 roots, to three C6 roots, to four posterior division of the middle trunks, to one musculocutaneous nerve, and to two suprascapular nerves. Sixty-seven percent of the cases acquired M4 or more in the deltoid muscle, 88% in the infraspinatus muscle, and 100% in the biceps brachii muscle. Twenty-five percent of the cases acquired M4 or more in the triceps brachii muscle and the wrist extensor muscles. These results were much better than formerly reported for adult cases by other authors. No functional compromise of the trapezius muscle was noted. The accessory nerve neurotization can be used safely and effectively in neurosurgical reconstruction of the brachial plexus palsy in infants. © 1994 Wiley-Liss, Inc.     

Femoral branch to obturator nerve transfer for restoration of thigh adduction following iatrogenic injury

Obturator nerve injury is a rare complication of pelvic surgery. A variety of management strategies have been reported, with conservative measures being the preferred treatment in most cases. While nerve transfer has become more commonly used for restoring brachial plexus injuries, it has rarely been applied to the lower extremities. To the authors' knowledge, this is the first report of an obturator nerve neurotization. A patient presented 7 months after an iatrogenic right obturator nerve palsy due to pelvic surgery for gynecological malignancy. She underwent a femoral branch to obturator nerve transfer to restore right thigh adduction. Ten months after the neurotization procedure, there was electromyographic evidence of almost complete obturator nerve reinnervation. At 1 year postoperatively, the patient had regained full muscle strength on thigh adduction and a normal gait. Nerve transfer could therefore be a good option in patients with obturator nerve injury whose symptoms fail to respond to conservative medical therapy.