Restoration of elbow flexion 16 years after brachial plexus root avulsion

To restore elbow flexion in brachial plexus lesions or cervical root avulsions, surgical nerve reconstruction can be attempted after approximately 6 months. If the reconstruction is not successful or was not performed, tendon transfer may improve the function of a paralysed limb. The selection of the muscle for transfer can be influenced by strengthening potentially available muscles by a myo-feedback method.     

Operations to restore elbow flexion after brachial plexus injuries

We have reviewed 50 patients at a mean period of 2.7 years after operations to restore elbow flexion lost as a result of traction injuries of the brachial plexus. A variety of operations were used and, in general, patient satisfaction was high. Objectively, however, the power in the transferred muscles was poor; less than half of the patients had a significant improvement in function. Poor control of the shoulder often compromised the result. Latissimus dorsi and triceps transfers proved most reliable, and some Steindler flexorplasties also gave satisfactory results. Pectoralis major transfers were disappointing and we do not recommend their use in women.     

Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries

Despite technical advances, the ability to restore motor function following a brachial plexus avulsion is limited. Twenty patients who suffered the loss of elbow flexion following a brachial plexus avulsion injury underwent a neurotization procedure in an attempt to restore that lost function. Of 16 patients who underwent intercostal to musculocutaneous nerve anastomosis, seven obtained good elbow flexion. Four patients who no longer had a viable biceps brachialis muscle underwent an anastomosis between transposed intercostal nerves and a free vascularized gracilis muscle grafted to the position of the biceps. Two of these patients obtained good elbow flexion. Although synkinesis between the biceps brachialis and the inspiratory muscles can be demonstrated during coughing and deep inspiration, the patients learn to flex their reinnervated biceps brachialis muscle and maintain flexion independent of respiration.     

Musculocutaneous neurotization to restore elbow flexion in brachial plexus paralysis

Brachial plexus injuries may result in devastating paralysis, especially if they involve all the roots. The upper roots are often traumatized, and therefore elbow flexion is usually lost. The prognosis of these injuries is grave if root avulsions are present and the paralysis includes the hand as well. The current management of brachial plexus injuries should be early, aggressive microsurgical reconstruction of the plexus, combining various neurotizations with intraplexus and extraplexus nerve donors. Following this principle, we present the results of musculocutaneous neurotization in our unit, as well as a review of the literature on this subject. Our results are comparable to those reported in the literature, and indicate that the strongest function is achieved after neurotization via intraplexus donors, while some extraplexus donors (i.e., phrenic and accessory nerve) can offer equally strong elbow flexion, especially if they are used in combination. Neurotization of the musculocutaneous nerve should be one of the primary goals in the reconstruction of the injured plexus, since the return of elbow flexion is of paramount importance in daily activity. The restoration of function is ensured if the stronger and healthier motor donors are dedicated to the neurotization of the musculocutaneous nerve. Sometimes in order to match the axonal number of the target to the lower number of axons offered by the donors, two or more donor nerves may be driven to the same target, such as the musculocutaneous nerve.     

Secondary operation for elbow flexion reconstruction after brachial plexus lesion

Summary Elbow flexion plays a key role in the overall function of the upper extremity. In the case of unilateral complete brachial plexus lesion, restoration of elbow flexion will dramatically increase the patient's chances of regaining bimanual prehension. Furthermore, depending on the type of reconstruction, stability of the glenohumeral joint as well as some supination function of the forearm can be restored to a varying degree at the same time. Depending on the level of brachial plexus lesion and/or reinnervation, different reconstructive procedures are available. In order to select the best treatment option for the patient it is necessary to known the extent of the lesion of the brachial plexus and/or ventral upper arm muscles, to time the operation appropriately, to be aware of all treatment possibilities and to recall the special problems of tendon transfer for brachial plexus patients. Our concept is based on our experience with more than 1100 patients presenting a brachial plexus lesion between 1981 and 1996 and treated in our institution. There were 528 operative revisions of the brachial plexus. Some 225 patients underwent secondary muscle/tendon transfers. In 35 patients elbow flexion was reconstructed by bipolar latissimus dorsi transfer (n = 10), triceps-to-biceps transfer (n = 15), modified flexor/pronator muscle mass proximalization (n = 6) and multiple-stage free functional muscle transfer after intercostal nerve transfer (n = 4).      

Restoration of elbow flexion in brachial plexus avulsion injury: comparing spinal accessory nerve transfer with intercostal nerve transfer.

This study was performed to compare the clinical outcome of 2 types of commonly used nerve transfers, the spinal accessory nerve transfer and the intercostal nerve transfer. This study was a prospective randomized parallel trial involving 205 patients presenting between 1989 and 1994. All patients were males ranging in age from 16 to 43 years. All patients underwent surgery within 6 months of injury. Spinal accessory nerve transfer was performed in 130 patients; better results were obtained in terms of less operative time, fewer blood transfusions, fewer immediate complications, and better motor function (very good and good power in 83% of patients). Intercostal nerve transfer was performed in 75 patients; better results were observed in terms of earlier electromyographic evidence of motor reinnervation, improvement in protective sensation, and reduction of pain. However, very good and good motor recovery was observed in only 64% of patients. There was no significant difference with regard to tidal volume, vital capacity, and the FEV1 to FEV ratio before and after surgery in either group. Smoking adversely affected the rate of recovery. Spinal accessory nerve transfer should be used when motor function of the elbow flexors is the major concern. Intercostal nerve transfer should be performed in patients who need both motor and sensory reconstruction and in those who have chronic pain syndrome after brachial plexus injury.     

Steindler flexorplasty of the elbow in obstetric brachial plexus injuries

A Steindler flexorplasty at the elbow was performed in 26 patients with an obstetric brachial plexus lesion because of deficient elbow flexion. Follow-up after a mean of 2.9 years (range, 1-7 years) showed a good functional result in 23 cases, whereas 3 primary failures were noted. In one case, a recurrent dislocation of the elbow was seen 3 years after the initial flexorplasty. Steindler flexorplasty is a comparatively simple operation and gives very reliable results. It should be preferred above other, more elaborate muscle transfers for loss of elbow flexion.     

Transposition of local muscles to restore elbow flexion in brachial plexus palsy

Between 1994 and 2001, triceps to biceps transfers were done in 10 men and a transfer of the forearm flexors and extensors (Steindler procedure) in nine. All had suffered from a post-traumatic lesion of their brachial plexus, resulting in loss of elbow flexion. Their mean age at the time of the original accident was 27 years (range 16-50 years) and at the time of muscle transfer 35 years (range 22-56 years), with a mean observation period of 20 months (range 6-51 months). In 16 patients, a neurosurgical procedure had been performed after the trauma, and in 22 patients other reconstructive operations had been done. Transfer of the forearm flexors and extensors resulted in active elbow flexion with a mean of 94 degrees (range 70-130 degrees ). After triceps to biceps transposition a mean of 109 degrees (range 70-140 degrees ) was reached. A mean deficit of passive extension of 12 degrees (range 0-30 degrees ) remained after the Steindler procedure, and of 5 degrees (range 0-10 degrees ) after triceps to biceps transposition. Two complications occurred with the Steindler procedure. The transfer of the triceps muscle to the tendon of the biceps and the transfer of the forearm flexors or extensors on loss of elbow flexion, therefore, resulted in adequate movement and strength. Both procedures involve operating close to the elbow joint and had minimal complications. The triceps to biceps transfer is particularly suitable for co-contraction of triceps and biceps.     

Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries

OBJECT: In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve. METHODS: The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG). The mean patient age was 26.4 years (range 16-45 years) and the mean time from injury to surgery was 3.8 months (range 2.5-7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+ in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient. CONCLUSIONS: The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.     

Free muscle transplantation combined with intercostal nerve crossing for reconstruction of elbow flexion and wrist extension in brachial plexus injuries.

Complete paralysis due to traumatic brachial plexus injury is extremely difficult to treat when the injury affects whole nerve roots and when motor function fails to show any signs of recovery. Seddon has suggested that arthrodesis of the shoulder and amputation at the humerus, combined with the use of a functional upper extremity prosthesis, was the most practical procedure available. Since 1965, in cases of irreparable lesions such as complete root avulsion type injuries, we have performed direct intercostal nerve crossing to the musculocutaneous nerve without free nerve graft to achieve elbow flexion. However, it is necessary to operate on the patient within 6 months following the injury to obtain good results. In the past there was no procedure for dealing with delayed cases of complete brachial plexus palsy. However, with the advent of microsurgical techniques, new approaches have become open to us. Since 1978, we have reconstructed the elbow flexor by the combined surgery of free muscle transplantation with intercostal nerve crossing in delayed cases of complete paralysis. This article introduces the operative technique and the results we have obtained.     

Obstetrical brachial plexus palsy. Prediction of outcome in upper root injuries

Thirty obstetrical brachial plexus palsies involving the upper roots were retrospectively reviewed. There were 20 C5-C6 palsies and ten C5-C6-C7 palsies in which recovery of C7 occurred by the end of the first month. Recovery of elbow flexion at 3 months, C7 involvement and high birthweight were the best early predictors of outcome, but all were unreliable when used separately. In combination, recovery of elbow flexion and birthweight predicted the final outcome reasonably satisfactorily, particularly when elbow flexion at 9 months, and not 3 months was considered (risk of error = 13%). Brachial plexus reconstruction may therefore be justified when there was initial C7 involvement associated with increased birthweight and poor elbow flexion at 6-9 months.     

Restoration of elbow function in severe brachial plexus paralysis via muscle transfers

SUMMARY: Reconstruction of elbow function in severe or late brachial plexus injuries represents a challenge to the reconstructive microsurgeons. The current sophisticated techniques of nerve reconstruction in combination with secondary local or free functional muscle transfers, may offer satisfactory outcome. Latissimus dorsi can be transferred as a pedicled or free muscle to restore elbow function. We present our experience with elbow reanimation in late cases of brachial plexus paralysis utilising latissimus dorsi muscle transfer. From 1998 to 2006 we operated 103 patients with brachial plexus paralysis. Amongst these patients, 21 were late cases and underwent latissimus dorsi muscle transfer for elbow reanimation. Ten patients had free latissimus dorsi transfer for elbow flexion. Free latissimus dorsi muscle was neurotised either directly via three intercostals in three patients or with a nerve transfer procedure using the contralateral seventh cervical nerve root in seven patients. Care was taken to maintain the proper tension to the muscle, which must hold the elbow in static flexion of about 120 degrees at the end of the procedure. Powerful elbow flexion (M4-M4+) or extension (M4) was obtained after the first 3 months in all patients who had an ipsilateral pedicled latissimus dorsi transfer. In the group of free muscle transfers, elbow flexion was seen after 6-8 months. After the initiation of muscle contraction, eight of the patients regained elbow flexion of M3-M4+. Latissimus dorsi muscle transfer is a reliable method for elbow reanimation. Appropriate postoperative management is also an important factor to obtain better outcome.     

Latissimus dorsi muscle transfer for restoration of elbow flexion after brachial plexus disruption

Five patients between 10 and 46 years old were reviewed after a latissimus dorsi muscle transfer to restore elbow flexion. Loss of elbow flexion resulted from traumatic brachial plexus paralysis in all five patients. All had some weakness in other muscle groups in the upper extremity. The follow-up period was from 25 to 68 months (average = 39.4 months). A range of motion of 0 degrees/115 degrees, 10 degrees/100 degrees, 0 degrees/110 degrees, 0 degrees/70 degrees was obtained. After the transfer, three patients could supinate the forearm, and supination of 90 degrees, 15 degrees, and 10 degrees was measured. Two patients could lift 4 lb, while two others could lift 1 and 1.5 lb, respectively. Evaluation of activities of daily living by a standardized test revealed disappointing results. The two patients with less than 90 degrees elbow flexion had initial paralysis of the latissimus dorsi muscle at the time of injury. This procedure should not be done unless the latissimus dorsi muscle is normal.     

Triceps to biceps transfer to restore elbow flexion in three patients with brachial plexus palsy.

Between April 1994 and April 1998, triceps to biceps transfers were done for three men with post-traumatic lesions of the brachial plexus and consequent loss of elbow flexion. Their mean age at the time of their accidents was 33 years (range 19-41) and at the time of muscle transfer 40 years (28-46), with a mean observation period of 21 months (12-31). The transfer resulted in active elbow flexion in all patients with a mean of 113 degrees (90 degrees-130 degrees) and a degree of strength 4-5 (contraction against resistance) with no remaining deficit of passive extension. Two patients were satisfied with the result of the operation and the other was content. No complications were noted. The transfer of the triceps muscle to the tendon of the biceps muscle on loss of elbow flexion resulted in adequate movement and degree of strength. The triceps to biceps transfer involves operating close to the elbow joint and minimal complications, is cosmetically satisfactory, and is particularly suitable for co-contraction of triceps and biceps.