Nerve transfer in brachial plexus traction injuries.

Brachial plexus palsy due to traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Nerve transfer is the only possibility for repair in cases of spinal nerve-root avulsion. This technique was analyzed in 37 patients with 64 reinnervation procedures of the musculocutaneous and/or axillary nerve using upper intercostal, spinal accessory, and regional nerves as donors. The most favorable results, with an 83.8% overall rate of useful functional recovery, were obtained in patients with upper brachial plexus palsy in which regional donor nerves, such as the medial pectoral, thoracodorsal, long thoracic, and subscapular nerves, had been used. The overall rates of recovery for the spinal accessory and upper intercostal nerves were 64.3% and 55.5%, respectively, which are significantly lower. The authors evaluate the results of nerve transfer and analyze different donor nerves as factors influencing the prognosis of surgical repair.     

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.     

神经移位治疗臂丛上干根性撕脱伤

目的 阐明神经移位治疗臂丛上干根性撕脱伤的疗效。方法 1990年3月至1998年2月,对14例臂丛干根性撕脱伤患者,将同侧胸前外侧神经直接移位于腑神经,胸背神经直接移位于肌皮神经,以重建三角肌、肱三头肌功能。结果 术后随访1年以上,三角肌肌力8例恢复至M4,4例M3,2例为M3－;肱二头肌肌力14例均恢复至M4。结论 运用同侧胸前外侧神经、胸背神经移闰的方法治疗臂丛上干根性撕脱伤,疗效较好;对原有的臂丛中、下干神经的主要功能无明显影响。     

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.     

Nerve transfer to the triceps after brachial plexus injury: report of four cases

These case reports review the clinical outcomes of 4 patients who underwent nerve transfer to a triceps motor branch of the radial nerve. Mean follow-up was 26 ± 15 months. Two patients had a transfer using an ulnar nerve fascicle to the flexor carpi ulnaris muscle, yielding a motor recovery of grade M5 elbow extension strength in one case and M4+ in the other. In 1 patient, a thoracodorsal nerve branch was used as the donor; this patient recovered M4 strength. One patient had a transfer using a radial nerve fascicle to the extensor carpi radialis longus muscle and recovered M5 strength. These outcomes indicate that expendable fascicles of the ulnar, thoracodorsal, and radial nerves are viable donors in the surgical reconstruction of elbow extension.     

Technique of intercostal nerve harvest and transfer for various neurotization procedures in brachial plexus injuries

Brachial plexus palsy caused by traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Neurotization is the only possibility for repair in cases of spinal nerve-root avulsion. Intercostal neurotization is a well-established technique in the treatment of some severe brachial plexus lesions in adults. In this article, we describe our experience and technique of intercostal nerve harvest for transfer in various neurotization strategies in posttraumatic brachial plexus reconstruction. Intercostal nerve harvest is a technique requiring meticulous technique and careful dissection along with proper hemostasis. It is also very important to preserve the serratus anterior muscle insertion and keep soft tissue stripping to a minimal. We do not osteotomize the ribs and believe that this adds to the morbidity and length of the procedure. Neurotization using intercostal nerves is a very viable procedure in avulsion injuries of the brachial plexus; however, there is some concern that in the presence of ipsilateral phrenic nerve palsy, it may lead to a significant compromise of respiratory function. In our experience, this is negligible with good long-term results.     

Improvements after mod Quad and triangle tilt revision surgical procedures in obstetric brachial plexus palsy

AIM To compare outcomes of our revision surgical operations in obstetric brachial plexus palsy(OBPP) patients to results of conventional operative procedures at other institutions. METHODS We analyzed our OBPP data and identified 10 female and 10 male children aged 2.0 to 11.8 years(average age 6.5 years), who had prior conventional surgical therapies at other clinics. Of the 20 patients, 18 undergone triangle tilt, 2 had only mod Quad. Among 18 patients, 8 had only triangle tilt and 10 had also mod Quad as revision surgeries with us. We analyzed the anatomical improvements and functional modified Mallet statistically before and after a year post-revision operations.RESULTS Pre-revision surgery average modified Mallet score was 12.0 ± 1.5. This functional score was greatly improved to 18 ± 2.3(P 0.0001) at least one-year after revision surgical procedures. Radiological scores(PHHA and glenoid version) were also improved significantly to 31.9 ± 13.6(P 0.001),-16.3 ± 11(P 0.0002), at least one-year after triangle tilt procedure. Their mean pretriangle tilt(yet after other surgeon's surgeries) PHHA, glenoid version and SHEAR were 14.6 ± 21.7,-31.6 ± 19.3 and 16.1 ± 14.7 respectively.CONCLUSION We demonstrate here, mod Quad and triangle tilt assuccessful revision surgical procedures in 20 OBPP patients, who had other surgical treatments at other clinics before presenting to us for further treatment.     

Sever-L'Episcopo tendon transfer in obstetric brachial plexus palsy

Obstetric brachial plexus palsy produces functional and cosmetic impairment. The Sever-L'Episcopo procedure has been successfully used to improve external rotation, primarily in younger patients. Previous studies have shown steady improvement in motion and function for 1 year from the date of surgery, with little additional change beyond this period. This is a retrospective study of 7 patients who have had the procedure at the Shriners Hospital for Children in Tampa, Florida. Functional and cosmetic results have been uniformly excellent at an average follow-up of 1 year 3 months. No complications have occurred. In addition, the degree of improvement seen in our relatively older patient population has not been previously detailed in the literature.     

Nerve transfers in adult brachial plexus injuries: my methods

The reconstructive strategies for avulsion in-juries vary from patient to patient and over time,continue to evolve depending on the surgeon's philosophy, available facilities and therapy, the elapsed time from injury to intervention, the severity of injury, and patient age and motivation.The author's results show that nerve transfer can obtain an average of 60 degrees (range, 20 degrees - 180 degrees) of shoulder elevation without shoulder arthrodesis, M3 to M4 muscle strength of elbow flexion, M2 to M4 elbow extension, and M3 finger flexion and sensation. Intrinsic hand function was obtained with help of dynamic splinting for interphalangeal joint extension and arthrodesis of thumb joints asa post for opposition.     

Nerve transfers in children with traumatic partial brachial plexus injuries

Brachial plexus trauma is a rare condition in children except for obstetrical lesions, for which nerve grafting is generally proposed. Two children (9 and 12 years old) with C5 and C6 traumatic brachial plexus avulsion lesions are presented, where elbow flexion and shoulder abduction and external rotation were the functions to be restored. Nerve transfers have been performed. Shoulder abduction was restored by an accessory-to-suprascapular nerve transfer in one patient, while the triceps long head motor branch was transferred to the axillary nerve in both patients. Fascicles of the ulnar and median nerve were transferred respectively to the biceps muscle nerve and the brachialis motor branch. At 11 months follow-up, the elbow flexion scored M4 and the shoulder abduction recovered in both patients. No complications were observed. Nerve transfers currently used in adult patients may be applied in children with traumatic partial brachial plexus palsies.     

Functioning free-muscle transfer for brachial plexus injury

Functioning free-muscle transfers are now an important, even essential, tool in the current management of patients with brachial plexus injury. They are indicated for the restoration of elbow flexion in patients who delay presentation(those seen after 6 to 9 mo). Double free-muscle transfers provide the possibility of simple grasp function when combined with nerve transfers or grafts for restoration of shoulder motion, hand sensation, and triceps function.     

Selection of grip function in double free gracilis transfer procedures after complete paralysis of the brachial plexus

Double free gracilis transfer (DFGT) procedures introduced by Doi et al have resulted in significant improvement in maintaining functional prehensile hand after total brachial plexus injury (TBPI). However, not all patients with satisfactory recovery of finger motion could improve their prehensile function. The use of reconstructed hand in daily activities was examined retrospectively to plan individual grip function, depending on the patient's own demand.Thirty patients who had had reconstruction with DFGT procedures were evaluated retrospectively according to total active motion (TAM), power grip, hook grip, and pinch function. Power grip was evaluated by holding a bottle and hook grip by lifting a weight. Only 11 patients (36%) had very light pulp-to-pulp pinch, 11 (36%) had power grip, and 25 (83%) had hook grip. The mean weight that could be carried by hook grip was 1.3 kg. The mean TAM was 43 degrees. Pain sensation was the only encouraging sensation recovery, radiating to the chest.Fine movements of the hand like pinching require well-developed exquisite control of movements. TBPI patients have the contralateral normal limb, which they always prefer, only using their reconstructed hand when the activity requires both hands, such as when holding a bottle to open its cap or lifting bags when the contralateral normal hand is already engaged. For performance of these actions, hook grip and power grip are the useful prehensile hand functions that can be obtained after DFGT. Selection of grip functions should be done according to patient needs, and the late-stage reconstructive hand operations should be decided according to preferred grip 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。     

臂丛神经损伤的分型与手术方案

随着高速交通的发展,臂丛神经损伤已是常见创伤,据上海华山医院手外科不完全统计,20世纪70年代(改革开放前)臂丛神经损伤年手术约400人次,而2010年全年臂丛神经损伤手术已达4000人次.经过40年的努力,我国臂丛神经损伤的诊治已从大城市大医院普及到中小城市的县级及区级医院.     

肋间神经移位治疗全臂丛根性撕脱伤两种术式的比较

目的　比较肋间神经移位直接与肌皮神经缝合 ,和通过皮神经移植桥接肌皮、肋间神经两种术式的疗效。方法　 3 2例全臂丛根性撕脱伤 ,其中将肋间神经游离 10～ 13cm ,经电刺激证实含有运动神经束后切断 ,与肌皮神经直接缝合 2 0例。在肋间神经与肌皮神经间移植皮神经 (平均长 10 .2cm) 12例。术后平均随访 3年 ,观察肱二头肌屈肘功能及肌力的恢复。结果　肌力达 3级或 3级以上的 ,神经移位组占 75 % ,神经移植组为 2 5 %。结论　肋间神经与肌皮神经缝接后 ,屈肘功能恢复明显 ,直接缝合组优于神经移植桥接组 (P <0 .0 1)。