[Vascularized nerve trunk grafts. Technic and results of 27 cases]

Reliability of functioning free muscle transfer and vascularized ulnar nerve grafting for elbow flexion in complete brachial plexus palsy

We compared outcomes of primary vascularized ulnar nerve grafts from the C5 root neurotizing biceps and brachialis muscles, and gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve, as a primary or salvage procedure after complete brachial plexus injury. At 45 months, three of eight primary vascularized ulnar nerve graft patients regained grade 4 elbow flexion, while one regained grade 3. All 13 primary gracilis transfer patients regained grade 4 elbow flexion. Four patients with vascularized ulnar nerve grafts failed and subsequently had salvage functioning free muscle transfer procedures resulting in delayed recovery. Although vascularized ulnar nerve graft-based primary reconstructions can provide useful elbow flexion, this was achieved in less than half the cases. We consider primary gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve as the most reliable reconstruction for the restoration of elbow flexion in complete brachial plexus injury.

LEVEL OF EVIDENCE

IV.

Reconstruction of complete palsies of the adult brachial plexus by root grafting using long grafts and nerve transfers to target nerves

PURPOSE

We report on the results we obtained with reconstruction for total paralysis of the brachial plexus using long nerve grafts that connect nonavulsed roots to the musculocutaneous and radial nerve. Nerve transfers were performed to restore function of the suprascapular nerve, triceps long head, and pectoralis major muscle.

METHODS

We studied 22 young adults with complete brachial plexus palsy who had surgical repair an average of 5 months after trauma. Nerve grafts connected the C5 root to the musculocutaneous nerve. The C6 root was connected by grafts to the radial nerve. When the C6 root was avulsed, the levator scapulae motor branch was connected by grafts to the triceps long head motor branch. In 13 patients, the platysma motor branch was transferred to the medial pectoralis nerve through a long nerve graft. The suprascapular nerve was repaired through transfer of the accessory nerve. Outcomes were assessed an average of 27 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale.

RESULTS

All but one patient recovered some shoulder abduction, with a mean range of recovered shoulder abduction of 57°. Pectoralis major reinnervation was observed in 9 of the 13. Twenty patients recovered full elbow flexion and achieved at least grade M3 strength. Among the 10 patients in whom the C6 root was grafted to the radial nerve, 4 patients recovered active elbow extension with biceps co-contraction. All patients in whom the levator scapulae nerve was connected to the triceps long head recovered active elbow extension, albeit weak. Double lesions of the musculocutaneous nerve were identified in 4 patients.

CONCLUSIONS

Accessory to suprascapular nerve transfer, levator scapulae nerve transfer to the triceps long head and C5 root grafting to the musculocutaneous nerve is now our preferred method of reconstruction in total palsies of the brachial plexus.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Results of c5 root grafting to the musculocutaneous nerve using pedicled, vascularized ulnar nerve grafts

PURPOSE

Vascularized nerve grafts are indicated for the repair of large nerve defects. In brachial plexus injuries, the poor prognosis for functional hand reconstruction when the lower roots are avulsed makes the ulnar nerve a potential donor for vascularized nerve grafts. We report on the results we obtained with reconstruction of elbow flexion using long pedicled ulnar nerve grafts that connected the C5 root to the musculocutaneous nerve.

METHODS

We prospectively studied 8 young adults with complete brachial plexus palsy with avulsion of the lower roots, who had surgical repair an average of 4.6 months after trauma. Pedicled ulnar nerve grafts, averaging 30 cm long, connected the C5 root to the musculocutaneous nerve. In order to rescue misdirected axons that could have regenerated into the cutaneous branch of the musculocutaneous nerve, we transferred this branch to the motor branch of the extensor carpi radialis brevis muscle. Outcomes for all 8 patients were assessed an average of 26.7 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale.

RESULTS

None of the patients recovered elbow flexion or wrist extension greater than M2.

CONCLUSIONS

In brachial plexus injuries, reconstruction of elbow flexion using a long, pedicled, vascularized nerve graft produces unsatisfactory results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.