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Richard E, Coulet B, Chammas M, Lazerges C. Morbidity of long head of the triceps motor branch neurotization to the axillary nerve: Retrospective subjective and objective assessment of triceps brachii strength after transfer. Orthop Traumatol Surg Res 2022; 108:103280. [PMID: 35477040 DOI: 10.1016/j.otsr.2022.103280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Morbidity is considered to be negligible in Leechavengvongs transfer (LT) of the long head of the triceps onto the axillary nerve, but the assessment methods used may lack reproducibility. We assessed triceps strength after LT objectively by the isokinetic technique, addressing the following questions: Is strength lowered after LT compared to the healthy limb? And 2) is there a good correlation between isokinetic dynamometry and subjective assessment? HYPOTHESIS Isokinetic measurement shows a decrease in triceps strength at peak torque after LT compared to the healthy limb, and this morbidity is underestimated on subjective assessment. MATERIAL AND METHODS This single-center retrospective study included patients undergoing LT for axillary nerve trunk palsy between 2008 and 2020, with M5 triceps preoperatively on the British Medical Research Council (BMRC) scale. Twenty patients, with a mean age of 25±9years (range, 15-48years) were assessed at a mean 58±47months (range, 6-174months). Elbow extension strength was assessed on a standardized questionnaire, BMRC isometric test and isokinetic test on an angular course of 90° at 60°/sec and 180°/sec concentrically and 30°/sec excentrically. RESULTS Strength at 60°/sec and 180°/sec concentrically and 30°/sec excentrically was significantly lower than in the healthy limb: respectively, -17Nm, -15Nm, and -16Nm, (p<0.001) for a mean -23%. Loss of strength was mainly severe on isokinetic testing and mild on isometric testing. Seven patients reported contracture (35%), 12 fatigue (60%), and 3 weakness (15%). Satisfaction with extension strength was excellent or good for respectively 12 (60%) and 8 patients (40%). Triceps strength was graded BMRC M4 in 9 triceps (11%) and M5 in 11 (55%). DISCUSSION After LT, isokinetic measurement found generally severe loss of triceps strength, but without subjective impact on everyday life. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Emmanuelle Richard
- Département de Chirurgie Orthopédique, Unité de Chirurgie de la Main et du Membre Supérieur, Chirurgie des Nerfs Périphériques, CHU Montpellier, 191, avenue du Doyen Gaston Giraud, 34295 Montpellier cedex 5, France.
| | - Bertrand Coulet
- Département de Chirurgie Orthopédique, Unité de Chirurgie de la Main et du Membre Supérieur, Chirurgie des Nerfs Périphériques, CHU Montpellier, 191, avenue du Doyen Gaston Giraud, 34295 Montpellier cedex 5, France
| | - Michel Chammas
- Département de Chirurgie Orthopédique, Unité de Chirurgie de la Main et du Membre Supérieur, Chirurgie des Nerfs Périphériques, CHU Montpellier, 191, avenue du Doyen Gaston Giraud, 34295 Montpellier cedex 5, France
| | - Cyril Lazerges
- Département de Chirurgie Orthopédique, Unité de Chirurgie de la Main et du Membre Supérieur, Chirurgie des Nerfs Périphériques, CHU Montpellier, 191, avenue du Doyen Gaston Giraud, 34295 Montpellier cedex 5, France
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Tahir H, Osama M, Beg MSA, Ahmed M. Comparison of Anterior vs. Dorsal Approach for Spinal Accessory to Suprascapular Nerve Transfer in Patients With a Brachial Plexus Injury and Its Outcome on Shoulder Function. Cureus 2022; 14:e26543. [PMID: 35936186 PMCID: PMC9346609 DOI: 10.7759/cureus.26543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background Brachial plexus injuries are frequently encountered in the domain of plastic surgery, mostly secondary to road traffic accidents, gunshot injuries, or falls from a height. Many modalities have been described in the management, depending on the level and duration of the injury. C5, C6 and C5, C6, C7 are two common patterns in which nerve repair and transfers are described. At our center, we practice spinal accessory to suprascapular nerve transfer in all patients with upper trunk brachial plexus injury. There are two described approaches for the spinal accessory nerve to suprascapular nerve transfer, i.e. anterior or dorsal. The rationale for doing the posterior approach is that this approach avoids damaging the suprascapular nerve at its entrance in the suprascapular notch under the suprascapular ligament during exploration due to traction. Materials and methods This is a retrospective study with a consecutive sampling of 23 patients presenting at Liaquat National Hospital, Karachi, with upper trunk brachial plexus injuries during the time period from January 2016 to December 2017, i.e. two years. We divided these 23 patients into two groups, one with the anterior approach and the other with a dorsal approach for spinal accessory to suprascapular nerve transfer for shoulder abduction. The mean duration of post-surgical follow-up was from 18 to 24 months and recovery and functional outcomes were assessed. Results Out of the 23 patients that were included, 10 patients were operated on with an anterior approach and 13 with a posterior approach. Fifty percent (50%) of patients operated with the anterior approach and 84% of patients with the posterior showed the best motor grade recovery of M4, respectively, with better performance in patients with the posterior approach as compared to the anterior approach. Conclusion We advocate taking a posterior approach for spinal accessory to suprascapular nerve transfer for shoulder abduction, as it has shown better results with reliable outcomes concerning shoulder abduction, angle of abduction, and range of motion.
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Trofin D, Trofin DM, Luca C, Matei D, Ignat B, Stamate T. Interdisciplinary perspectives of rehabilitation in adult brachial plexus palsies. BALNEO AND PRM RESEARCH JOURNAL 2022. [DOI: 10.12680/balneo.2022.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The aim of this study is to demonstrate that the interdisciplinary approach could have a positive result on the rehabilitation program in brachial plexus paralysis in adults. The prevalence of brachial plexus injuries is currently increasing worldwide, mainly due to the growing number of car accidents, extreme sports or work-related injuries. In this study we chose to present an analysis of one complex surgical case of brachial plexus paralysis, with clinical and electrophysiological investigations. (1) Background: Current reconstructive surgical nerve transfer procedures aim to rehabilitate elbow flexion in such cases. Surgical strategies are based not only on clinical evaluation or investigations by magnetic resonance imaging but also on classical electrophysiological methods, such as electromyography (EMG). (2) Methods: Along with the other types of therapies already established, in the case of this pathology, Transcranial Magnetic Stimulation (TMS) is also used, which provides valuable information about cortical reorganization models concomitant with surgical procedures for nerve reconstruction in the last 3 decades. (3) Results: The study shows that interdisciplinary leads to a faster and more complex rehabilitation of the patient with brachial plexus paralysis and that electrophysiological signals could predict constant motor benefits when associated with rehabilitation programs.
Keywords: brachial plexus; electromyography; transcranial magnetic stimulation; neuroplasticity;
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Affiliation(s)
- Dan Trofin
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa” Iași, Romania
| | | | - Catalina Luca
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa” Iași, Romania
| | - Daniela Matei
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa” Iași, Romania
| | - Bogdan Ignat
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa” Iași, Romania
| | - Teodor Stamate
- Department of Plastic and Recontructive Surgery, “Sf. Spiridon” Emergency Hospital, Iași
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Rasulić L, Savić A, Lepić M, Kovačević V, Vitošević F, Novaković N, Mandić-Rajčević S, Samardžić M. Viable C5 and C6 Proximal Stump Use in Reconstructive Surgery of the Adult Brachial Plexus Traction Injuries. Neurosurgery 2020; 86:400-409. [PMID: 31173135 DOI: 10.1093/neuros/nyz179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 01/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In patients with only upper (C5, C6) brachial plexus palsy (BPP), the pooled international data strongly favor nerve transfers over nerve grafts. In patients with complete BPP, some authors favor nerve grafts for the restoration of priority functions whenever there is a viable proximal stump. OBJECTIVE To evaluate functional recovery in cases of upper and complete BPP where only direct graft repair from viable proximal stumps was performed. METHODS The study included 36 patients (24 with complete BPP and 12 with only upper BPP) operated on over a 15-yr period. In all cases, direct graft repair from C5 to the musculocutaneous and the axillary nerve was performed. In cases with complete BPP, additional procedures included either direct graft repair from C6 to the radial nerve and the medial pectoral nerve or the dorsal scapular nerve transfer to the branch for the long head of the triceps. RESULTS The use of C5 proximal stump grafts (in both complete and upper BPP) resulted in satisfactory elbow flexion in 26 patients (72.2%) and satisfactory shoulder abduction in 22 patients (61.1%). The use of C6 proximal stump grafts in patients with complete BPP resulted in satisfactory elbow extension in 5 (50%) and satisfactory shoulder adduction in another 5 (50%) patients. CONCLUSION Although nerve transfers generally enable better restoration of priority functions, in cases of infraganglionary injuries, especially in shorter defects, it is also necessary to consider direct graft repair, or at least its combination with nerve transfers, as a potentially beneficial treatment modality.
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Affiliation(s)
- Lukas Rasulić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery, Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Andrija Savić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery, Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Milan Lepić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
| | - Vojin Kovačević
- Clinic for Neurosurgery, Clinical Center Kragujevac, Kragujevac, Serbia.,Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Filip Vitošević
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Neuroradiology Department, Center for Radiology and MRI, Clinical Center of Serbia, Belgrade, Serbia
| | - Nenad Novaković
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia.,Medical Faculty of the Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Stefan Mandić-Rajčević
- Innovation Centre of the Faculty for Technology and Metallurgy, University of Belgrade, Belgrade, Serbia
| | - Miroslav Samardžić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery, Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
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Prasad GL. An All-Anterior Approach for Quadruple Nerve Transfer for Upper Trunk Brachial Plexus Injuries. World Neurosurg 2018; 120:e651-e659. [PMID: 30165220 DOI: 10.1016/j.wneu.2018.08.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The most commonly performed nerve transfers in upper trunk (UT) or partial brachial plexus injuries (BPIs) include the spinal accessory nerve to suprascapular nerve, Oberlin, and, lately, radial nerve (RN) (branch to triceps) to axillary nerve (AN) transfers. Routinely, the former 3 procedures are performed through an anterior approach (supraclavicular plus infraclavicular), while the triceps branch of the RN-AN transfer has been performed through a posterior approach with the patient in either the prone or semilateral position, which requires a separate incision in the posterior arm. The aim of the present study was to report the outcomes for 4 cases of quadruple nerve transfers performed for UT BPI using an all-anterior approach. METHODS The functional outcomes of 4 consecutive cases of UT BPI treated using an all-anterior approach were analyzed in terms of improvement in motor power and range of motion at the shoulder and elbow joints. RESULTS The mean age was 27.5 years (range, 16-40). All had sustained injuries from road traffic accidents. The mean injury to surgery interval was 4.5 months (range, 3-6). Of the 4 patients, 2 each had pre- and postganglionic injuries. All 4 patients had 0 of M0 power in shoulder abduction and external rotation, and elbow flexion. At a mean follow-up of 28.6 months, the average shoulder abduction was 157°, with an average of 82° of external rotation. The mean elbow flexion was 104°. CONCLUSIONS This technique appears to be feasible, with good-to-excellent outcomes achieved without requiring a separate posterior arm incision for the RN-AN transfer.
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Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India.
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Abstract
The restoration of shoulder function after brachial plexus injury represents a significant challenge facing the peripheral nerve surgeons. This is owing to a combination of the complex biomechanics of the shoulder girdle, the multitude of muscles and nerves that could be potentially injured, and a limited number of donor options. In general, nerve transfer is favored over tendon transfer, because the biomechanics of the musculotendinous units are not altered. This article summarizes the surgical techniques and clinical results of nerve transfers for restoration of shoulder function.
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Souza FHM, Bernardino SN, Filho HCA, Gobbato PL, Martins RS, Martins HAL, Silva-Néto RP. Comparison between the anterior and posterior approach for transfer of the spinal accessory nerve to the suprascapular nerve in late traumatic brachial plexus injuries. Acta Neurochir (Wien) 2014; 156:2345-9. [PMID: 25326278 DOI: 10.1007/s00701-014-2222-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the transfer of the spinal accessory nerve to the suprascapular nerve through the anterior or posterior approach in patients with late traumatic brachial plexus injuries. METHODS This study includes patients with late brachial plexus injuries that underwent a spinal accessory-to-suprascapular nerve transfer. They were divided into two equal groups, A and B, in which the spinal accessory nerve was transferred to the suprascapular nerve, respectively, through the anterior or posterior approach. Narakas's scale for assessment of the abduction of the arm and rotation of the shoulder was used. RESULTS We studied 20 male patients with an age ranging from 18 to 42 years. In groups A and B, the mean age was 28 ± 5.5 and 26 ± 7.7 years, respectively. The time interval between injury and surgery was 9.5 ± 1.6 and 10.9 ± 2.5 months for groups A and B (p = 0.12), respectively. In the 20 patients in groups A and B, we obtained a strength of shoulder abduction at 30°, respectively, M3 (in 4 and 5), M2 (in 4 and 2), M1 (in 2 and 2) and M0 (in zero and 1) (p = 0.5). Regarding external rotation, group A showed M2 in only one patient and M0 in nine, while in group B, M3, in four; M2, in three; and M0, in three. In group B, the best results were observed in relation to the recovery of external rotation (p = 0.008). CONCLUSIONS Better results in terms of external arm rotation were obtained when spinal accessory-to-suprascapular nerve transfer was performed using the posterior approach.
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Sedain G, Sharma MS, Sharma BS, Mahapatra AK. Outcome after delayed Oberlin transfer in brachial plexus injury. Neurosurgery 2011; 69:822-7; discussion 827-8. [PMID: 21670719 DOI: 10.1227/neu.0b013e31822848eb] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nerve transfers following traumatic brachial plexus injuries are infrequently operated on after 6 months of injury because myoneural degeneration may set in before nerve regeneration can occur. An exception may lie in transferring healthy donor nerve fascicles directly onto an injured recipient nerve close to the motor point. This is especially true of the Oberlin transfer in which ulnar nerve fascicle(s) are transferred onto the damaged nerve to the biceps. OBJECTIVE This retrospective observational study evaluated the outcome of the Oberlin transfer on bicipital power in patients with upper trunk/C5,6,7 root level injuries operated on after 6 months of injury. METHODS Using a standard infraclavicular exposure, the musculocutaneous nerve was followed to its branch to the biceps. Distal to this, the ulnar nerve was skeletonized and a constituent motor fascicle was transferred onto the nerve to biceps. Medical Research Council (MRC) motor power grading was assessed every 3 months following surgery. Patients with a follow-up less than 12 months were excluded. RESULTS Nine patients operated on after an average of 12.2 months (range, 7-24 months) following injury qualified for the study. At an average follow-up of 26.7 months (range, 12-41 months), all patients had ≥ 2/5 biceps power. Seven patients (77.8%) had useful biceps function ≥ 3/5 MRC score. A single patient operated on 24 months after injury gained 4/5 MRC biceps power. CONCLUSION The Oberlin transfer is a useful salvage procedure in patients presenting after 6 months of a brachial plexus injury.
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Affiliation(s)
- Gopal Sedain
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Bhandari PS, Bhatoe HS. Is fascicular selection by nerve stimulation techniques a necessity in selective nerve transfers targeted at restoration of elbow flexion in upper brachial plexus injuries? INDIAN JOURNAL OF NEUROTRAUMA 2011. [DOI: 10.1016/s0973-0508(11)80008-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Zyaei A, Saied A. Functional outcome of ulnar nerve fascicle transfer for restoration of elbow flexion in upper brachial plexus injury. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2009. [DOI: 10.1007/s00590-009-0558-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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