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Diaz LC, Vergara-Amador E. Transfer of Motor Fascicle From the Ulnar Nerve to the Axillary Nerve by Posterior Access. New Approach. Tech Hand Up Extrem Surg 2024; 28:171-176. [PMID: 38651619 DOI: 10.1097/bth.0000000000000483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
ABSTRACT We describe a new technique of transferring the motor branch ulnar nerve (UN) to the axillary nerve (AN) by posterior approach. Three patients with C5, C6, and C7 brachial plexus injury were operated. By supraclavicular approach, the spinal accessory was transferred to the suprascapular nerve. By posterior approach in the arm, the AN was identified within the quadrilateral space, and the UN was identified medially with intrafascicular dissection of a motor fascicle, which is lifted to 4 cm in length and transferred to AN. By medial approach, a motor branch from the median nerve is transferred to the biceps nerve. At a follow-up minimum of 10 months, the maximum abduction was 160 and the minimum 90 degrees. This technique, neurotization of the AN with fascicles of the UN, spinal accessory to suprascapular nerve, and median nerve branch to biceps nerve are indicated in C5-C7 avulsion when there is no radial nerve available. LEVEL OF EVIDENCE Level IV.
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Socolovsky M, Lu JCY, Zarra F, Wei CK, Chang TNJ, Chuang DCC. Effects of COVID-19 Pandemic in Patients with a Previous Phrenic Nerve Transfer for a Traumatic Brachial Plexus Palsy. J Brachial Plex Peripher Nerve Inj 2024; 19:e20-e26. [PMID: 38868462 PMCID: PMC11168810 DOI: 10.1055/s-0044-1787296] [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: 01/11/2024] [Accepted: 05/03/2024] [Indexed: 06/14/2024] Open
Abstract
Background With the advent of the coronavirus disease 2019 (COVID-19) pandemic, some doubts have been raised regarding the potential respiratory problems that patients who previously underwent a phrenic nerve transfer could have. Objectives To analyze the effects of the coronavirus infection on two populations, one from Argentina and another from Taiwan. Specific objectives were: (1) to identify the rate of COVID in patients with a history of phrenic nerve transfer for treatment of palsy; (2) to identify the overall symptom profile; (3) to compare Argentinian versus Taiwanese populations; and (4) to determine if any phrenic nerve transfer patients are at particular risk of more severe COVID. Methods A telephonic survey that included data regarding the number of episodes of acute COVID-19 infection, the symptoms it caused, the presence or absence of potential or life-threatening complications, and the status of COVID-19 vaccination were studied. Intergroup comparisons were conducted using the nonparametric Mann-Whitney U test, with categorical variables conducted using either the Pearson χ2 analysis or the Fisher's exact test, as appropriate. Results A total of 77 patients completed the survey, 40 from Taiwan and 37 from Argentina. Fifty-five (71.4%) developed a diagnosis of COVID. However, among these, only four had any level of dyspnea reported (4/55 = 7.3%), all mild. There were also no admissions to hospital or an intensive care unit, no intubations, and no deaths. All 55 patients isolated themselves at home. Conclusions It can be concluded that an acute COVID-19 infection was very well tolerated in our patients. (Level of evidence 3b, case reports).
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Affiliation(s)
- Mariano Socolovsky
- Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Francisco Zarra
- Department of Neurosurgery, Sanatorio Guemes, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Chen Kuan Wei
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Kakinoki R, Ohtani K, Ohta S, Ikeguchi R, Akagi M, Goto K. Treatment of Complete Brachial Plexus Injuries Using Double Free Muscle Transfer. J Hand Surg Am 2023:S0363-5023(23)00497-5. [PMID: 37921713 DOI: 10.1016/j.jhsa.2023.09.005] [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: 04/13/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE The purpose of this study was to examine the surgical outcomes of double free muscle transfer (DFMT) performed in patients with complete brachial plexus injury (BPI). METHODS We retrospectively analyzed the outcomes of DFMT for 12 patients with complete BPI who were followed up for more than 2 years after the final muscle transplantation. Their mean age was 29 years (range, 18-41). Three patients underwent contralateral C7 nerve root transfer before the DFMT. The range of motion (ROM) of the shoulder, elbow, and fingers was measured. Patient-reported outcome measures, including Disability of the Shoulder, Arm, and Hand (DASH) scores and visual analog scale (VAS) scores for pain, were also examined. RESULTS The mean shoulder ROM against gravity was 22° ± 8° in abduction and 33° ± 5° in flexion. Seven patients underwent phrenic nerve (PhN) transfer to the suprascapular nerves, and five exhibited asymptomatic lung impairment on spirography more than 2 years after PhN transfer. The mean elbow ROM against gravity was 111° ± 9° in flexion and -32° ± 7° in extension. All patients obtained elbow flexion >90° against a 0.5-kg weight. All patients obtained touch sensation and two recognized warm and cold sensations in the affected palm. The mean total active motion of the affected fingers was 44° ± 11°. All patients exhibited hook function of the hands. The mean preoperative and postoperative DASH scores were 70.3 ± 13.4 and 51.8 ± 15.9, respectively. The mean pain VAS score was 28 ± 31 at the final follow-up. CONCLUSIONS Double free muscle transfer provided patients with complete brachial plexus palsy with good elbow flexion and hand hook functions. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ryosuke Kakinoki
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan.
| | - Kazuhiro Ohtani
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
| | - Souichi Ohta
- Department of Orthopedic Surgery, Kansai Electric Power Hospital, Osaka, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masao Akagi
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
| | - Koji Goto
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
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Anantavorasakul N, Piakong P, Kittithamvongs P, Malungpaishrope K, Uerpairojkit C, Leechavengvongs S. Posterior Deltoid Function After Transfer of Branch to the Long Head Triceps Brachii of the Radial Nerve to the Anterior Branch of the Axillary Nerve. J Hand Surg Am 2023; 48:1168.e1-1168.e6. [PMID: 35803783 DOI: 10.1016/j.jhsa.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 02/22/2022] [Accepted: 04/08/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to evaluate the function of the posterior part of the deltoid after nerve transfer of the long head triceps branch of the radial nerve to the anterior branch of the axillary nerve in patients with an upper brachial plexus injury or isolated axillary nerve injury. METHODS We retrospectively reviewed 26 patients diagnosed with an upper brachial plexus injury or isolated axillary nerve injury who underwent nerve transfer of the long head triceps muscle branch of the radial nerve to the anterior branch of the axillary nerve in our institute between 2012 and 2017. Data on age, sex, the mechanism of injury, the pattern of injury, and operative treatment were collected from medical records. Preoperative and postoperative clinical examinations, including motor powers of shoulder abduction and extension according to Medical Research Council grading, were evaluated. At a minimum of 2 years after the operation, we evaluated the recovery of the posterior deltoid function using the swallow-tail test. RESULTS Twenty-two patients (84.6%) had recovery of posterior deltoid function confirmed by the swallow-tail test. There were 23 patients (88.5%) who achieved at least Medical Research Council grade 4 of shoulder abduction. CONCLUSIONS Nerve transfer from the branch to the long head triceps to the anterior branch of the axillary nerve is an effective technique for restoring deltoid function in an upper brachial plexus injury or isolated axillary nerve injury. This technique can provide shoulder abduction and shoulder extension, which are the functions of the posterior deltoid muscle. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Navapong Anantavorasakul
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand.
| | - Pongsiri Piakong
- Orthopaedic Oncology Unit, Institute of Orthopaedics, Lerdsin Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Piyabuth Kittithamvongs
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Kanchai Malungpaishrope
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Chairoj Uerpairojkit
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Somsak Leechavengvongs
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
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Jawad AM, Duraku LS, Susini F, Chaudhry T, George S, Jester A, Power DM. Resect, rewire, and restore: Nerve transfer salvage of neurological deficits associated with soft tissue tumors in a retrospective cohort series at a tertiary reconstructive center. J Plast Reconstr Aesthet Surg 2023; 85:523-533. [PMID: 37280143 DOI: 10.1016/j.bjps.2023.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/28/2023] [Accepted: 04/07/2023] [Indexed: 06/08/2023]
Abstract
AIMS We aimed to explore the effectiveness of nerve transfer as an intervention to restore neurological deficits caused by extremity tumors through direct nerve involvement, neural compression, or as a consequence of oncological surgery. METHODS A retrospective cohort study of consecutive cases was conducted, including all patients who underwent nerve transfers to restore functional deficits in limbs following soft tissue tumor resection. The threshold for a successful nerve transfer was a BMRC motor grade of 4/5 and sensory grade of 3-3+/4 with protective sensation. RESULTS In total, 29 nerve transfers (25 motor and 4 sensory) were completed in 11 patients, aged 12-70 years at referral, over a 6-year period to 2020. This included 22 upper limb and 3 lower limb motor nerve transfers. The timing of delayed nerve transfer reconstructions was 1-15 months following primary oncological resection, with immediate simultaneous reconstructions performed in 4 cases. The threshold for success was achieved in 82% of upper limb and 33% of lower limb motor nerve transfers, while all sensory transfers were successful in restoring protective sensation. CONCLUSION Nerve transfer surgery, a well-established technique in restoring deficits following traumatic nerve injury, is further demonstrably relevant in extremity oncological reconstruction, especially as it can be performed remotely to the tumor location or resection site and introduces a healthy nerve or fascicle to rapidly reinnervate distal muscles without sacrificing major function. This study further illustrates the importance of early recognition and referral to specialist services where multi-disciplinary surgical resection and reconstructive planning can be conducted. LEVEL OF EVIDENCE IV Clinical Case Series.
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Affiliation(s)
- Ali M Jawad
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Liron S Duraku
- Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Francesca Susini
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Tahseen Chaudhry
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Samuel George
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Andrea Jester
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, United Kingdom
| | - Dominic M Power
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom.
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Chuieng-Yi Lu J, An-Jou Lin J, Lee CH, Nai-Jen Chang T, Chwei-Chin Chuang D. Phrenic Nerve as an Alternative Donor for Nerve Transfer to Restore Shoulder Abduction in Severe Multiple Root Injuries of the Adult Brachial Plexus. J Hand Surg Am 2023; 48:954.e1-954.e10. [PMID: 35610117 DOI: 10.1016/j.jhsa.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/26/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Nerve transfer is the gold standard to restore shoulder abduction in acute brachial plexus injuries. The aim of this study was to compare the phrenic nerve (Ph) to the spinal accessory nerve (XI) as the donor nerve for this purpose. METHODS A retrospective chart review was performed on 136 patients with acute brachial plexus injuries who received a nerve transfer of the shoulder with either the Ph (94 patients) or XI (42 patients). Each group was divided into 3 subgroups based on the recipient nerve. The maximum degree of shoulder abduction was recorded after 2 years of postoperative follow-up. A generalized estimating equation model was performed to examine the variables affecting shoulder abduction over time. RESULTS The maximum degrees of shoulder abduction achieved were 61.9° ± 38.7° in patients with Ph and 51.1° ± 37.3° in patients with XI. More than M3 shoulder abduction was achieved by 67% of patients with Ph versus 59% of patients with XI. The regression analysis showed that the age at the time of surgery correlated more with the functional outcome over time than the choice of donor nerve. CONCLUSIONS In multiple root brachial plexus injuries, the Ph exhibited similar outcomes to the XI for shoulder abduction. Our routine exploration of the supraclavicular plexus exposes the Ph conveniently for nerve transfer. The phrenic nerve should be considered as an alternative when the XI is not available or is reserved for secondary reconstruction. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Jennifer An-Jou Lin
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Che-Hsiung Lee
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan.
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Crowe CS, Shin AY, Pulos N. Iatrogenic Nerve Injuries of the Upper Extremity: A Critical Analysis Review. JBJS Rev 2023; 11:01874474-202301000-00003. [PMID: 36722824 DOI: 10.2106/jbjs.rvw.22.00161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
» Iatrogenic nerve injuries may occur after any intervention of the upper extremity. » Causes of iatrogenic nerve lesions include direct sharp or thermal injury, retraction, compression from implants or compartment syndrome, injection, patient positioning, radiation, and cast/splint application, among others. » Optimal treatment of iatrogenic peripheral nerve lesions relies on early and accurate diagnosis. » Advanced imaging modalities (e.g., ultrasound and magnetic resonance imaging) and electrodiagnostic studies aid and assist in preoperative planning. » Optimal treatment of iatrogenic injuries is situation-dependent and depends on the feasibility of direct repair, grafting, and functional transfers.
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Affiliation(s)
- Christopher S Crowe
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington
| | - Alexander Y Shin
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
| | - Nicholas Pulos
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
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Restoration of Grasp after Single-Stage Free Functioning Gracilis Muscle Transfer in Traumatic Adult Pan-Brachial Plexus Injury. Plast Reconstr Surg 2023; 151:133-142. [PMID: 36219863 DOI: 10.1097/prs.0000000000009787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND A variety of approaches have been described to obtain rudimentary grasp after traumatic pan-brachial plexus injury in adults. The aim of this study is to evaluate hand prehension after a gracilis single-stage free functioning muscle transfer. METHODS Twenty-seven patients who underwent gracilis single-stage free functioning muscle transfer for elbow flexion and hand prehension after a pan-plexus injury were included. All patients presented with a minimum of 2 years of follow-up. Postoperative finger flexion, elbow flexion strength, preoperative and postoperative Disability of the Arm, Shoulder, and Hand questionnaire scores, secondary hand procedures, complications, and demographic characteristics were analyzed. RESULTS Twenty patients (74%) demonstrated active finger pull-through. Only six patients (25%) considered their hand function useful for daily activities. Disability of the Arm, Shoulder, and Hand score improved by 13.1 ± 13.7 ( P < 0.005). All patients were expected to require one secondary procedure (wrist fusion, thumb carpometacarpal fusion, and/or thumb interphalangeal fusion) because no extensor reconstruction was performed. These were performed in 89%, 78%, and 74% of patients, respectively. Four postoperative complications (hematoma, seroma, wound dehiscence, and skin paddle loss) occurred. No flap loss occurred. CONCLUSIONS In pan-plexus injuries, the use of a gracilis single-stage free functioning muscle transfer is an alternative to the double free functioning muscle transfer procedure and contralateral C7 transfer, especially for patients who are unable to undergo two to three important operations in a short period of time. Further research and studies are required to improve hand function in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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MALUNGPAISHROPE K, LEECHAVENGVONGS S, UERPAIROJKIT C, ANANTAVORASAKUL N, KITTITHAMVONGS P, DENSIRI-AKSORN W. Outcomes of Spinal Accessory Nerve and Intercostal Nerve Transfers for Shoulder Stabilisation and Elbow Extension in Patients with C 5,6,7 Root Avulsion Injury. J Hand Surg Asian Pac Vol 2022; 27:447-452. [DOI: 10.1142/s2424835522500540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Upper arm type brachial plexus palsy results in decreased shoulder and elbow function. Reanimation of shoulder and elbow function is beneficial in these patients. The aim of this study is to report the results of restoring the shoulder abduction and elbow extension in patients with C5,6,7 root avulsion injury by simultaneous transfer of the spinal accessory nerve for the supraspinatus muscle combined with the transferring of the sixth and seventh intercostal nerves for the serratus anterior muscle along with the third to fifth intercostal nerves to the triceps muscle. Methods: All patients who underwent the above set of nerve transfers and had at least 2 years of follow-up were included in the study. The outcome measures included the Medical Research Council (MRC) grading of motor strength of shoulder abduction and elbow extension and range of motion of shoulder abduction and shoulder external rotation. Results: The study included 10 patients with an average age of 27. The mean time from injury to surgery was 6 months and the mean follow-up period was 35 months. M4 grade shoulder abduction was restored in five patients, M3 grade in three patients and M2 grade in two. M4 grade elbow extension was achieved in four patients, M3 grade in four patients and M2 grade in two patients. The average arc of shoulder abduction and external rotation was 71° and −21°, respectively. Conclusions: The spinal accessory nerve and the sixth and seventh intercostal nerves transfer to the supraspinatus muscle and serratus anterior muscle with the third to fifth intercostal nerves transfer to the triceps muscle provided satisfactory results for both shoulder abduction and elbow extension in C5,6,7 root avulsion injury. Level of Evidence: Level IV (Therapeutic)
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Affiliation(s)
- Kanchai MALUNGPAISHROPE
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin General Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Somsak LEECHAVENGVONGS
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin General Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Chairoj UERPAIROJKIT
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin General Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Navapong ANANTAVORASAKUL
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin General Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Piyabuth KITTITHAMVONGS
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin General Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Worawit DENSIRI-AKSORN
- Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin General Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand
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Makeľ M, Sukop A, Kachlík D, Waldauf P, Whitley A, Kaiser R. Possible donor nerves for axillary nerve reconstruction in dual neurotization for restoring shoulder abduction in brachial plexus injuries: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1303-1312. [PMID: 34978005 DOI: 10.1007/s10143-021-01713-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/30/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
Restoring shoulder abduction is one of the main priorities in the surgical treatment of brachial plexus injuries. Double nerve transfer to the axillary nerve and suprascapular nerve is widely used and considered the best option. The most common donor nerve for the suprascapular nerve is the spinal accessory nerve. However, donor nerves for axillary nerve reconstructions vary and it is still unclear which donor nerve has the best outcome. The aim of this study was to perform a systematic review on reconstructions of suprascapular and axillary nerves and to perform a meta-analysis investigating the outcomes of different donor nerves on axillary nerve reconstructions. We conducted a systematic search of English literature from March 2001 to December 2020 following PRISMA guidelines. Two outcomes were assessed, abduction strength using the Medical Research Council (MRC) scale and range of motion (ROM). Twenty-two studies describing the use of donor nerves met the inclusion criteria for the systematic review. Donor nerves investigated included the radial nerve, intercostal nerves, medial pectoral nerve, ulnar nerve fascicle, median nerve fascicle and the lower subscapular nerve. Fifteen studies that investigated the radial and intercostal nerves met the inclusion criteria for a meta-analysis. We found no statistically significant difference between either of these nerves in the abduction strength according to MRC score (radial nerve 3.66 ± 1.02 vs intercostal nerves 3.48 ± 0.64, p = 0.086). However, the difference in ROM was statistically significant (radial nerve 106.33 ± 39.01 vs. intercostal nerve 80.42 ± 24.9, p < 0.001). Our findings support using a branch of the radial nerve for the triceps muscle as a donor for axillary nerve reconstruction when possible. Intercostal nerves can be used in cases of total brachial plexus injury or involvement of the C7 root or posterior fascicle. Other promising methods need to be studied more thoroughly in order to validate and compare their results with the more commonly used methods.
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Affiliation(s)
- Michal Makeľ
- Department of Plastic Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic. .,Department of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Andrej Sukop
- Department of Plastic Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - David Kachlík
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care Medicine, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Adam Whitley
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,Department of General Surgery, Third Faculty of Medicine, Charles University and University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic
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González Rodríguez A, González Porto SA, Comellas Melero N, Arufe MC. Acellular nerve graft enriched with mesenchymal stem cells in the transfer of the phrenic nerve to the musculocutaneous nerve in a C5-C6 brachial plexus avulsion in a rat model. Microsurgery 2022; 42:57-65. [PMID: 34661312 DOI: 10.1002/micr.30829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/14/2021] [Accepted: 09/17/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Phrenic nerve transfer has been shown to achieve good nerve regeneration in brachial plexus avulsion. Acellular nerve allografts (ANAs) showed inferior results to autografts, which is why its use with mesenchymal stem cells (MSCs) is currently being studied. The aim is to study the effect of BM-MSCs associated with ANAs in a rat model of phrenic nerve transfer to the musculocutaneous nerve in a C5-C6 avulsion. MATERIAL AND METHODS 42 Wistar-Lewis rats underwent a C5-C6 lesion in the right forelimb by excising a 3 mm segment from both roots, followed by a phrenic nerve transfer to the musculocutaneous nerve associated with the interposition of a three types of nerve graft (randomly distributed): control (autograft) group (n = 12), ANAs group (n = 12), and ANAs + BM-MSCs group (n = 18) After 12 weeks, amplitude and latency of the NAP and the compound motor action potential (CMAP) were measured. Biceps muscles were studied by histological analysis and nerve grafts by electron microscopy and fluorescence analysis. RESULTS Statistically significant reductions were found in latency of the CMAP between groups control (2.48 ± 0.47 ms) and experimental (ANAs: 4.38 ± 0.78 ms, ANAs + BM-MSCs: 4.08 ± 0.85 ms) and increases in the amplitude of the CMAP between groups control (0.04388 ± 0.02 V) and ANAs + BM-MSCs (0.02275 ± 0.02 V), as well as in the thickness of the myelin sheath between groups control (0.81 ± 0.07 μm) and experimental (ANAs: 0.72 ± 0.08 μm, ANAs + BM-MSCs: 0.72 ± 0.07 μm) and in the area of the myelin sheath between groups control (13.09 ± 2.67 μm2 ) and ANAs (10.01 ± 2.97 μm2 ) (p < .05). No statistically significant differences have been found between groups ANAs and ANAs + BM-MSCs. CONCLUSIONS This study presents a model for the study of lesions of the upper trunk and validates the autologous graft as the gold standard.
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Affiliation(s)
- Alba González Rodríguez
- Research Group on Cell Therapy and Regenerative Medicine; Physiotherapy, Biomedical Sciences and Medicine Department, A Coruña University (CHUAC. INIBIC), A Coruña, Spain
| | | | - Nerea Comellas Melero
- Research Group on Cell Therapy and Regenerative Medicine; Physiotherapy, Biomedical Sciences and Medicine Department, A Coruña University (CHUAC. INIBIC), A Coruña, Spain
| | - María C Arufe
- Research Group on Cell Therapy and Regenerative Medicine; Physiotherapy, Biomedical Sciences and Medicine Department, A Coruña University (CHUAC. INIBIC), A Coruña, Spain
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12
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Abdolrazaghi H, Rahmati J, Delavari C, Molaei H. Treatment of Brachial Plexus Injury Following Transaxillary Thyroidectomy. World J Plast Surg 2021; 10:114-116. [PMID: 34912676 PMCID: PMC8662683 DOI: 10.29252/wjps.10.3.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/01/2021] [Indexed: 10/31/2022] Open
Abstract
Minimally invasive surgeries are widespread and technically enhancing. Thyroidectomy is a common surgery and non-invasive adjustments make it more interesting. Neighbor neurovascular bundles need to be protected during minimally invasive thyroidectomy. A 15 yr old female who underwent minimally invasive thyroidectomy due to nodule, had presented with upper brachial plexus injury, without proper recovery despite physiotherapy cessions. She was operated in 2 stage reconstructive surgeries. First, musculocutaneous nerve innervated by 2 branches of median and ulnar nerves. Then, in a compound operation, axillary nerve innervated by long head branch of triceps nerve and suprascapular nerve by accessory nerve. She gained good function of upper limb. Minimally invasive operations in head and neck area can be disastrous, if surgeons do not consider anatomical points. Brachial plexus reconstructive surgeries are complicated operations to preserve hand functions following iatrogenic injuries.
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Affiliation(s)
- Hosseinali Abdolrazaghi
- Department of Hand & Reconstructive Surgery, Sina Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Javad Rahmati
- Department of Plastic & Reconstructive Surgery, Razi Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Department of Plastic & Reconstructive Surgery, IKHC, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Changiz Delavari
- Department of Plastic & Reconstructive Surgery, IKHC, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hojjat Molaei
- Department of Hand & Reconstructive Surgery, Sina Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Department of Plastic & Reconstructive Surgery, IKHC, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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13
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Estrada RG, Bacca J, Socolovsky M. A novel dual nerve transfer for restoration of shoulder function and sensory recovery of the hand, in patients with C567 traumatic root avulsion of the brachial plexus. Clin Neurol Neurosurg 2021; 210:107005. [PMID: 34741973 DOI: 10.1016/j.clineuro.2021.107005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of our study is to determine the anatomical viability in cadavers of a novel doble nerve transfer technique for simultaneous reanimation of shoulder abduction and sensory recovery of the hand, in patients with brachial plexus injuries sustaining a C5-C6-C7 roots avulsion. These new transfers should be complemented in the clinical setting with other classic nerve transfers, i.e.: (1) a spinal accessory to suprascapular for shoulder abduction and stability, (2) ulnar nerve fascicles to the biceps branches of the musculocutaneous for elbow flexion, and (3) intercostal to triceps branches for elbow extension. METHODS The proposed surgical technique includes (1) transferring motor fascicles of the median nerve (MNF), as donors to the axillary nerve (AN), and (2) the whole medial antebrachial cutaneous nerve (MACN) to the lateral contribution (sensory) of the median nerve (LCMN), both without the use of interposed nerve grafts. These techniques were performed in eight cadaveric upper extremities. Analyzed variables were: donor and receptor nerves diameter, length and distance of donor and receptors nerves, and axonal count. RESULTS The mean distance between the MNF and its point of coaptation to the AN was 19 mm. The average length of each one of the MNF, after distal dissection, was 46.5 mm. The average diameter of each fascicle of the median nerve at its coaptation point with the axillary nerve was 0.8 mm, while the average diameter of the latter was 3.9 mm. The average distance between the MACN and its point of coaptation to the LCMN, was 16.5 mm. The average diameter of the MACN and the LCMN at their point of coaptation, were 2.7 mm and 3.5 mm, respectively. CONCLUSION These nerve transfers are anatomically viable and could be a complement for other currently used techniques that can be employed in severely injured C567 brachial plexus patients.
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Affiliation(s)
- Ricardo González Estrada
- Peripheral Nerve and Brachial Plexus Surgery Unit, Department of Neurosurgery, Clinica Bolivariana, Universidad Pontificia Bolivariana School of Medicine, Medellin, Colombia.
| | - Juliana Bacca
- Department of Pathology, University of Antioquia, Medellin, Colombia.
| | - Mariano Socolovsky
- Peripheral Nerve and Brachial Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina.
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Maurya S, Renganathan G, R V, Bharti R. Outcomes of Shoulder Functions in Spinal Accessory to Suprascapular Nerve Transfer in Brachial Plexus Injury: A Comparison between Anterior and Posterior Approach. Indian J Plast Surg 2021; 54:152-156. [PMID: 34239236 PMCID: PMC8257319 DOI: 10.1055/s-0041-1731255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background Restoration of shoulder functions is important in brachial plexus injury (BPI). The functional outcomes of spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer by the anterior supraclavicular approach and the posterior approach is a matter of debate. This article aims to compare the outcomes of the shoulder functions by the SAN to the SSN transfer using the two approaches. Methods Retrospective data was collected in 34 patients who underwent SAN to SSN transfer from January 2016 to June 2018. Group A included 16 patients who underwent nerve transfers by anterior approach, and Group B included 18 patients who underwent nerve transfers by posterior approach. Functional outcomes were measured by grading the muscle power as per the British Medical Research Council (MRC) grading (graded as M) and the range of motions (ROM) of the shoulder at 6 months and 18 months. Results Early recovery was seen in group B with 7 patients (39%) showing M1 abduction power at 6 months as compared with one patient (6%) in group A . This difference was statistically significant ( p value = 0.04). At 18 months, 10 patients (62%) in group A had good recovery (MRC grade ≥3), while 13 patients (72%) in group B had a good recovery. This difference was not found to be statistically significant (Fisher exact test p value = 0.71) There was no statistical difference in the outcomes of ROM in shoulder abduction, external rotation, and motor power at 18 months of follow-up. Conclusions Early recovery was observed in the anterior approach group at 6 months, however, there was no significant difference in the outcomes of shoulder functions in muscle power and ROM in the two groups at 18 months of follow-up.
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Affiliation(s)
- Sanjay Maurya
- Department of Plastic Surgery, AFMC, Pune, Maharashtra, India
| | | | | | - Rajiv Bharti
- Department of Plastic Surgery, AFMC, Pune, Maharashtra, India
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15
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Kang GHY, Yong FC. Shoulder abduction reconstruction for C5-7 avulsion brachial plexus injury by dual nerve transfers: spinal accessory to suprascapular nerve and partial median or ulnar to axillary nerve. J Plast Surg Hand Surg 2021; 56:87-92. [PMID: 34110973 DOI: 10.1080/2000656x.2021.1934842] [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] [Indexed: 10/21/2022]
Abstract
Results of shoulder abduction reconstruction in partial upper-type brachial plexus avulsion injuries are better when a triceps nerve is transferred to the axillary nerve in addition to the spinal accessory to suprascapular nerve transfer. However, in C5-7 avulsion injuries, the triceps nerve may be unavailable as a donor nerve. We report the results of an alternative neurotization to the axillary nerve using either a partial median or ulnar nerve. Patients with C5, 6 ± 7 avulsion injuries and weak triceps who underwent dual nerve transfers for shoulder abduction reconstruction were recruited for the study. The second neurotization to the axillary nerve was from either a partial median or ulnar nerve that had an expandable muscle innervation of ≥ M4 motor power. Patients were assessed for recovery of shoulder abduction and external rotation. Nine patients (median age = 23 years) underwent these dual neurotizations from March 2005 to April 2013. The median time to surgery was 4.5 months. Recovery of shoulder abduction averaged 114.4° (range 90°-180°) and external rotation averaged 136.3° (range 135°-140°). Final shoulder abduction power was > M3 in all 9 patients and ≥ M4 in 6 patients. One patient with partial median nerve transfer had transient hypoaesthesia in his thumb and index finger and another had a residual M4 power in his thumb and index finger flexors. In C5-7 avulsion injuries, dual nerve transfers of the spinal accessory to suprascapular nerve and partial median or ulnar nerve to axillary nerve are good options for shoulder abduction reconstruction with minimal morbidity. Level of evidence is level IV.
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Affiliation(s)
- Gavrielle Hui-Ying Kang
- Department of Hand & Reconstructive Microsurgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Fok-Chuan Yong
- Department of Hand & Reconstructive Microsurgery, Tan Tock Seng Hospital, Singapore, Singapore
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16
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Doi K, Sem SH, Ghanghurde B, Hattori Y, Sakamoto S. Pearls and Pitfalls of Phrenic Nerve Transfer for Shoulder Reconstruction in Brachial Plexus Injury. J Brachial Plex Peripher Nerve Inj 2021; 16:e1-e9. [PMID: 33584849 PMCID: PMC7875611 DOI: 10.1055/s-0041-1722979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/12/2020] [Indexed: 11/05/2022] Open
Abstract
Objectives
The purpose of this study was to report the functional outcomes of phrenic nerve transfer (PNT) to suprascapular nerve (SSN) for shoulder reconstruction in brachial plexus injury (BPI) patients with total and C5–8 palsies, and its pulmonary complications.
Methods
Forty-four out of 127 BPI patients with total and C5–8 palsies who underwent PNT to SSN for shoulder reconstruction were evaluated for functional outcomes in comparison with other types of nerve transfers. Their pulmonary function was analyzed using vital capacity in the percentage of predicted value and Hugh-Jones (HJ) breathless classification. The predisposing factors to develop pulmonary complications in those patients were examined as well.
Results
PNT to SSN provided a better shoulder range of motion significantly as compared with nerve transfer from C5 root and contralateral C7. The results between PNT and spinal accessory nerve transfer to SSN were comparable in all directions of shoulder motions. There were no significant respiratory symptoms in majority of the patients including six patients who were classified into grade 2 HJ breathlessness grading. Two predisposing factors for poorer pulmonary performance were identified, which were age and body mass index, with cut-off values of younger than 32 years old and less than 23, respectively.
Conclusions
PNT to SSN can be a reliable reconstructive procedure in restoration of shoulder function in BPI patients with total or C5–8 palsy. The postoperative pulmonary complications can be prevented with vigilant patient selection.
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Affiliation(s)
- Kazuteru Doi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan
| | - Sei Haw Sem
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan.,Department of Orthopaedics, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Bipin Ghanghurde
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan.,Hand surgery, Kusum Orthopedic Centre, Mumbai, Maharashtra, India.,Hand surgery, Wadia Hospital, Mumbai, Maharashtra, India.,Hand surgery, Surya Hospital, Mumbai, Maharashtra, India
| | - Yasunori Hattori
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan
| | - Sotetsu Sakamoto
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan
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17
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El-Gammal TA, El-Sayed A, Kotb MM, Abdel-Hamid UF, El-Gammal YT. Long-Term Outcome of Phrenic Nerve Transfer in Brachial Plexus Avulsion Injuries. Ann Plast Surg 2021; 86:188-192. [PMID: 33346562 DOI: 10.1097/sap.0000000000002611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years. PATIENTS AND METHODS Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years. RESULTS Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms. CONCLUSIONS The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.
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Affiliation(s)
- Tarek Abdalla El-Gammal
- From the Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
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18
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Ellabban MA, Sadek AF, Galhom A, Hafez AE, Ramadan A. Comparison between long and lower medial head triceps branches in dual neurotization for shoulder function restoration in upper brachial plexus palsy. Microsurgery 2020; 41:124-132. [PMID: 33296099 DOI: 10.1002/micr.30690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 07/28/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
PURPOSE In upper brachial plexus injury (UBPI), restoring shoulder function is crucial. This study compares the transfer of long and lower medial heads of triceps branches to the axillary nerve to achieve proper restoration of function. PATIENTS AND METHODS A retrospective comparative study was conducted between two groups of patients with (UBPI). Group I patients (10) [mean age: 19 ± 10.6 years] were managed by transferring triceps long head branch to axillary nerve while group II patients (8) [mean age: 26 ± 9.6 years] were managed by triceps lower medial head branch transfer. The mean time from injury to surgery was 6 ± 1.3 and 5 ± 1.7 months respectively. All patients were followed up for a minimum of 12 months with the assessment of VAS, DASH score, active range of motion (AROM) and strength of shoulder abduction and external rotation; in addition to shoulder endurance and strengths of donors. Postoperative, three-monthly, electrodiagnostic assessments were performed. RESULTS Postoperatively, the mean VAS and DASH scores; in addition to endurance time, showed significant enhancement in both groups. Patients in both groups have accomplished a mean abduction (AROM) of 98° ± 27.9 and 97° ± 11.9 respectively. The mean external rotation (AROM) was 48° ± 18.4 and 47° ± 9.2 respectively. Furthermore, group II patients had less triceps morbidity in addition to earlier and enhanced electrophysiological recovery. CONCLUSIONS Dual neurotization for shoulder function restoration in (UBPI) is capable of providing proper functional results with minimal donor morbidity. The triceps lower medial branch provides an excelling donor due to less triceps morbidity, extra length; yet, earlier and enhanced electrophysiological recovery.
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Affiliation(s)
- Mohamed A Ellabban
- Plastic and Reconstructive Surgery Unit, Suez Canal University Hospitals and Medical School, Ismailia, Egypt
| | - Ahmed Fathy Sadek
- Department of Orthopaedic Surgery, Hand and Microsurgery Unit, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ayman Galhom
- Department of Neurosurgery, Faculty of Medicine, Port Said University, Port Said, Egypt
| | - Ahmed E Hafez
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ahmed Ramadan
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Port Said University, Port Said, Egypt
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Zuo KJ, Gordon T, Chan KM, Borschel GH. Electrical stimulation to enhance peripheral nerve regeneration: Update in molecular investigations and clinical translation. Exp Neurol 2020; 332:113397. [PMID: 32628968 DOI: 10.1016/j.expneurol.2020.113397] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/16/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023]
Abstract
Peripheral nerve injuries are common and frequently result in incomplete functional recovery even with optimal surgical treatment. Permanent motor and sensory deficits are associated with significant patient morbidity and socioeconomic burden. Despite substantial research efforts to enhance peripheral nerve regeneration, few effective and clinically feasible treatment options have been found. One promising strategy is the use of low frequency electrical stimulation delivered perioperatively to an injured nerve at the time of surgical repair. Possibly through its effect of increasing intraneuronal cyclic AMP, perioperative electrical stimulation accelerates axon outgrowth, remyelination of regenerating axons, and reinnervation of end organs, even with delayed surgical intervention. Building on decades of experimental evidence in animal models, several recent, prospective, randomized clinical trials have affirmed electrical stimulation as a clinically translatable technique to enhance functional recovery in patients with peripheral nerve injuries requiring surgical treatment. This paper provides an updated review of the cellular physiology of electrical stimulation and its effects on axon regeneration, Level I evidence from recent prospective randomized clinical trials of electrical stimulation, and ongoing and future directions of research into electrical stimulation as a clinically feasible adjunct to surgical intervention in the treatment of patients with peripheral nerve injuries.
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Affiliation(s)
- Kevin J Zuo
- Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada; Neurosciences and Mental Health, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Tessa Gordon
- Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada; Neurosciences and Mental Health, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - K Ming Chan
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Gregory H Borschel
- Division of Plastic & Reconstructive Surgery, University of Toronto, Toronto, ON, Canada; Neurosciences and Mental Health, SickKids Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada.
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Texakalidis P, Hardcastle N, Tora MS, Boulis NM. Functional restoration of elbow flexion in nonobstetric brachial plexus injuries: A meta‐analysis of nerve transfers versus grafts. Microsurgery 2020; 40:261-267. [DOI: 10.1002/micr.30510] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/07/2019] [Accepted: 08/23/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Pavlos Texakalidis
- Department of Neurosurgery, School of MedicineEmory University Hospital Atlanta Georgia
| | - Nathan Hardcastle
- Department of Neurosurgery, School of MedicineEmory University Hospital Atlanta Georgia
| | - Muhibullah S. Tora
- Department of Neurosurgery, School of MedicineEmory University Hospital Atlanta Georgia
| | - Nicholas M. Boulis
- Department of Neurosurgery, School of MedicineEmory University Hospital Atlanta Georgia
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21
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Texakalidis P, Tora MS, Lamanna JJ, Wetzel J, Boulis NM. Combined Radial to Axillary and Spinal Accessory Nerve (SAN) to Suprascapular Nerve (SSN) Transfers May Confer Superior Shoulder Abduction Compared with Single SA to SSN Transfer. World Neurosurg 2019; 126:e1251-e1256. [PMID: 30898759 DOI: 10.1016/j.wneu.2019.03.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The restoration of shoulder function after brachial plexus injury is a high priority. Shoulder abduction and stabilization can be achieved by nerve transfer procedures including spinal accessory nerve (SAN) to suprascapular nerve (SSN) and radial to axillary nerve transfer. The objective of this study is to compare functional outcomes after SAN to SSN transfer versus the combined radial to axillary and SA to SSN transfer. METHODS This retrospective chart review included 14 consecutive patients with brachial plexus injury who underwent SAN to SSN transfer, 4 of whom had both SA to SSN and radial to axillary nerve transfer. RESULTS SAN to SSN transfer achieved successful shoulder abduction (≥M3) in 64.3% of this cohort (9/14). During the long-term follow-up, patients achieved an average increase of 67.5° in shoulder abduction. There was no association between motor recovery and time from injury to surgery, age, body mass index (BMI), sex, or smoking status. The 4 patients who had SAN to SSN combined with radial to axillary nerve transfer demonstrated a statistically significant increase in the range of abduction (median, 90° vs. 42.5°, respectively; P = 0.022) compared with those who had SAN to SSN transfer alone; however, the difference in Medical Research Council (MRC) grades (MRC > M3) did not reach statistical significance (P = 0.07). CONCLUSIONS Patients with brachial plexus injury and an intact C7 root could benefit from radial to axillary transfer in addition to SAN to SSN transfer. There was no association between recovery of shoulder abduction and time interval from injury to surgery, age, sex, smoking, and BMI.
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Affiliation(s)
- Pavlos Texakalidis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.
| | - Muhibullah S Tora
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jason J Lamanna
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeremy Wetzel
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas M Boulis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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22
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Midha R, Grochmal J. Surgery for nerve injury: current and future perspectives. J Neurosurg 2019; 130:675-685. [PMID: 30835708 DOI: 10.3171/2018.11.jns181520] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Abstract
In this review article, the authors offer their perspective on nerve surgery for nerve injury, with a focus on recent evolution of management and the current surgical management. The authors provide a brief historical perspective to lay the foundations of the modern understanding of clinical nerve injury and its evolving management, especially over the last century. The shift from evaluation of the nerve injury using macroscopic techniques of exploration and external neurolysis to microscopic interrogation, interfascicular dissection, and internal neurolysis along with the use of intraoperative electrophysiology were important advances of the past 50 years. By the late 20th century, the advent and popularization of interfascicular nerve grafting techniques heralded a major advance in nerve reconstruction and allowed good outcomes to be achieved in a large percentage of nerve injury repair cases. In the past 2 decades, there has been a paradigm shift in surgical nerve repair, wherein surgeons are not only directing the repair at the injury zone, but also are deliberately performing distal-targeted nerve transfers as a preferred alternative in an attempt to restore function. The peripheral rewiring approach allows the surgeon to convert a very proximal injury with long regeneration distances and (often) uncertain outcomes to a distal injury and repair with a greater potential of regenerative success and functional recovery. Nerve transfers, originally performed as a salvage procedure for severe brachial plexus avulsion injuries, are now routinely done for various less severe brachial plexus injuries and many other proximal nerve injuries, with reliably good to even excellent results. The outcomes from nerve transfers for select clinical nerve injury are emphasized in this review. Extension of the rewiring paradigm with nerve transfers for CNS lesions such as spinal cord injury and stroke are showing great potential and promise. Cortical reeducation is required for success, and an emerging field of rehabilitation and restorative neurosciences is evident, which couples a nerve transfer procedure to robotically controlled limbs and mind-machine interfacing. The future for peripheral nerve repair has never been more exciting.
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Affiliation(s)
- Rajiv Midha
- 1Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada; and
| | - Joey Grochmal
- 2Neurosurgery, University Medical Center, Lubbock, Texas
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Wang GB, Yu AP, Ng CY, Lei GW, Wang XM, Qiu YQ, Feng JT, Li T, Chen QZ, He QR, Ding F, Cui SS, Gu YD, Xu JG, Jiang S, Xu WD. Contralateral C7 to C7 nerve root transfer in reconstruction for treatment of total brachial plexus palsy: anatomical basis and preliminary clinical results. J Neurosurg Spine 2018; 29:491-499. [PMID: 30074443 DOI: 10.3171/2018.3.spine171251] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 03/14/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVEContralateral C7 (CC7) nerve root has been used as a donor nerve for targeted neurotization in the treatment of total brachial plexus palsy (TBPP). The authors aimed to study the contribution of C7 to the innervation of specific upper-limb muscles and to explore the utility of C7 nerve root as a recipient nerve in the management of TBPP.METHODSThis was a 2-part investigation. 1) Anatomical study: the C7 nerve root was dissected and its individual branches were traced to the muscles in 5 embalmed adult cadavers bilaterally. 2) Clinical series: 6 patients with TBPP underwent CC7 nerve transfer to the middle trunk of the injured side. Outcomes were evaluated with the modified Medical Research Council scale and electromyography studies.RESULTSIn the anatomical study there were consistent and predominantly C7-derived nerve fibers in the lateral pectoral, thoracodorsal, and radial nerves. There was a minor contribution from C7 to the long thoracic nerve. The average distance from the C7 nerve root to the lateral pectoral nerve entry point of the pectoralis major was the shortest, at 10.3 ± 1.4 cm. In the clinical series the patients had been followed for a mean time of 30.8 ± 5.3 months postoperatively. At the latest follow-up, 5 of 6 patients regained M3 or higher power for shoulder adduction and elbow extension. Two patients regained M3 wrist extension. All regained some wrist and finger extension, but muscle strength was poor. Compound muscle action potentials were recorded from the pectoralis major at a mean follow-up of 6.7 ± 0.8 months; from the latissimus dorsi at 9.3 ± 1.4 months; from the triceps at 11.5 ± 1.4 months; from the wrist extensors at 17.2 ± 1.5 months; from the flexor carpi radialis at 17.0 ± 1.1 months; and from the digital extensors at 22.8 ± 2.0 months. The average sensory recovery of the index finger was S2. Transient paresthesia in the hand on the donor side, which resolved within 6 months postoperatively, was reported by all patients.CONCLUSIONSThe C7 nerve root contributes consistently to the lateral pectoral nerve, the thoracodorsal nerve, and long head of the triceps branch of the radial nerve. CC7 to C7 nerve transfer is a reconstructive option in the overall management plan for TBPP. It was safe and effective in restoring shoulder adduction and elbow extension in this patient series. However, recoveries of wrist and finger extensions are poor.
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Affiliation(s)
- Guo-Bao Wang
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- 2Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
| | - Ai-Ping Yu
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- 2Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
| | - Chye Yew Ng
- 3Upper Limb Unit, Wrightington Hospital, Wigan, United Kingdom
| | - Gao-Wei Lei
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao-Min Wang
- 2Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
| | - Yan-Qun Qiu
- 2Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
| | - Jun-Tao Feng
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tie Li
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qing-Zhong Chen
- 4Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Qian-Ru He
- 5Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Fei Ding
- 5Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
| | - Shu-Sen Cui
- 6Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin Province, China
| | - Yu-Dong Gu
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian-Guang Xu
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Su Jiang
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wen-Dong Xu
- 1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- 2Department of Hand and Upper Extremity Surgery, Jing'an District Central Hospital, Shanghai, China
- 5Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, Nantong, Jiangsu Province, China
- 7State Key Laboratory of Medical Neurobiology, Collaborative Innovation Center of Brain Science, Fudan University, Shanghai, China
- 9National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Paul AW, Spinner RJ, Bishop AT, Shin AY, Rhee PC. Two Cases of Traumatic Brachial Plexus Injury With Complete Spinal Cord Injury. Hand (N Y) 2018; 13:NP27-NP31. [PMID: 30003796 PMCID: PMC6300176 DOI: 10.1177/1558944718787893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Traumatic brachial plexus injury (BPI) in patients with complete spinal cord injury (SCI) such as paraplegia or tetraplegia is a very rare and debilitating combined injury that can occur in high-energy traumas. Management of a BPI should be aimed at regaining strength for self-transfers and activities of daily living to restore independence. However, brachial plexus reconstruction (BPR) in this unique patient population requires considerable planning due to the combined elements of upper and lower motor neuron injuries. METHODS We present 2 cases of traumatic complete SCI with concomitant BPI with mean follow-up of 42 months after BPR. The first patient had a left C5-7 BPI with a T2 complete SCI. The second patient sustained a left C5-8 BPI with complete SCI at C8. RESULTS The first patient underwent BPR including free functioning muscle, intra- and extraplexal nerve transfers, and tendon transfers resulting in active elbow flexion and active elbow, finger, and thumb extension, but no recovery of shoulder function. While the second patient underwent extra-plexal nerve transfer to restore elbow flexion yet did not recover any function in the left upper extreimty. CONCLUSIONS Because extensive upper and lower motor neuron injuries are present in these combined injuries, treatment strategies are limited. Expectations should be tempered in these patients as traditional methods to reconstruct the brachial plexus may result in less than ideal functional outcomes due to the associated upper motor neuron injury.
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Affiliation(s)
| | | | | | | | - Peter C. Rhee
- Mayo Clinic, Rochester, MN, USA,Peter C. Rhee, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA.
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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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Yang KX, Zhang SH, Ge DW, Sui T, Chen HT, Cao XJ. A novel extradural nerve transfer technique by coaptation of C4 to C5 and C7 to C6 for treating isolated upper trunk avulsion of the brachial plexus. J Biomed Res 2018; 32:298-304. [PMID: 29884775 PMCID: PMC6117610 DOI: 10.7555/jbr.32.20180012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The study aimed to demonstrate the feasibility of an extradural nerve anastomosis technique for the restoration of a C5 and C6 avulsion of the brachial plexus. Nine fresh frozen human cadavers were used. The diameters, sizes, and locations of the extradural spinal nerve roots were observed. The lengths of the extradural spinal nerve roots and the distance between the neighboring nerve root outlets were measured and compared in the cervical segments. In the spinal canal, the ventral and dorsal roots were separated by the dura and arachnoid. The ventral and dorsal roots of C7 had sufficient lengths to anastomose those of C6. The ventral and dorsal of C4 had enough length to be transferred to those of C5, respectively. The feasibility of this extradural nerve anastomosis technique for restoring C5 and C6 avulsion of the brachial plexus in human cadavers was demonstrated in our anatomical study.
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Affiliation(s)
- Kai-Xiang Yang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Shao-Hua Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Da-Wei Ge
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Tao Sui
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hong-Tao Chen
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiao-Jian Cao
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Surgical strategy in extensive proximal brachial plexus palsies. Musculoskelet Surg 2018; 103:139-148. [PMID: 29961233 DOI: 10.1007/s12306-018-0552-x] [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: 03/21/2018] [Accepted: 06/24/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI). METHODS Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension. RESULTS Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%). CONCLUSIONS A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.
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Azzi AJ, AlNaeem H, Aubin-Lemay C, Kvann JC, Alam P, Retrouvey H, Aldekhayel S, Zadeh T. Restoration of shoulder motion using single- versus dual-nerve repair in obstetrical brachial plexus injury. J Neurosurg Pediatr 2018; 21:511-515. [PMID: 29473814 DOI: 10.3171/2017.11.peds17493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to compare shoulder abduction and external rotation (ER) after single-nerve repair of the upper trunk alone versus dual-nerve repair of both the upper trunk and the suprascapular nerve. METHODS A retrospective chart review of a single surgeon's experience repairing obstetrical brachial plexus injuries between June 1995 and June 2015 was performed. Eight patients underwent repair of the upper trunk alone, and 10 patients underwent repair of the upper trunk and the suprascapular nerve. Shoulder abduction and ER ranges of motion (ROMs) (in degrees) were recorded preoperatively and postoperatively. Postoperative ROM and the difference in ROM gained after surgery were compared by independent t-test analysis. RESULTS The mean follow-up time was 161.4 weeks (range 62-514 weeks, SD 124.0 weeks). The mean patient age at the time of surgery was 31.3 weeks (range 19.9-47.0 weeks, SD 6.9 weeks). The mean postoperative shoulder abduction ROMs were 145.0° (range 85°-180°, SD 39.4°) after single-nerve repair and 134.0° (range 90°-180°, SD 30.3°) after dual-nerve repair (p = 0.51). The mean postoperative shoulder ER ROMs were 67.5° (range 10°-95°, SD 28.8°) after single-nerve repair and 72.0° (range 10°-95°, SD 31.3°) after dual-nerve repair (p = 0.76). CONCLUSIONS The authors found no difference in shoulder abduction and ER between patients who underwent single-nerve repair of the upper trunk alone and those who underwent dual-nerve repair of both the upper trunk and the suprascapular nerve.
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Affiliation(s)
- Alain Joe Azzi
- 1Division of Plastic & Reconstructive Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec; and
| | - Hassan AlNaeem
- 1Division of Plastic & Reconstructive Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec; and
| | - Camille Aubin-Lemay
- 1Division of Plastic & Reconstructive Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec; and
| | - Julie Chakriya Kvann
- 1Division of Plastic & Reconstructive Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec; and
| | - Peter Alam
- 1Division of Plastic & Reconstructive Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec; and
| | - Helene Retrouvey
- 2Division of Plastic & Reconstructive Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Salah Aldekhayel
- 1Division of Plastic & Reconstructive Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec; and
| | - Teanoosh Zadeh
- 1Division of Plastic & Reconstructive Surgery, Royal Victoria Hospital, McGill University, Montreal, Quebec; and
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Jiang Y, Wang L, Lao J, Zhao X. Total brachial plexus injury: contralateral C7 root transfer to the lower trunk versus the median nerve. Neural Regen Res 2018; 13:1968-1973. [PMID: 30233071 PMCID: PMC6183026 DOI: 10.4103/1673-5374.239444] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Contralateral C7 (cC7) root transfer to the healthy side is the main method for the treatment of brachial plexus root injury. A relatively new modification of this method involves cC7 root transfer to the lower trunk via the prespinal route. In the current study, we examined the effectiveness of this method using electrophysiological and histological analyses. To this end, we used a rat model of total brachial plexus injury, and cC7 root transfer was performed to either the lower trunk via the prespinal route or the median nerve via a subcutaneous tunnel to repair the injury. At 4, 8 and 12 weeks, the grasping test was used to measure the changes in grasp strength of the injured forepaw. Electrophysiological changes were examined in the flexor digitorum superficialis muscle. The change in the wet weight of the forearm flexor was also measured. Atrophy of the flexor digitorum superficialis muscle was assessed by hematoxylin-eosin staining. Toluidine blue staining was used to count the number of myelinated nerve fibers in the injured nerves. Compared with the traditional method, cC7 root transfer to the lower trunk via the prespinal route increased grasp strength of the injured forepaw, increased the compound muscle action potential maximum amplitude, shortened latency, substantially restored tetanic contraction of the forearm flexor muscles, increased the wet weight of the muscle, reduced atrophy of the flexor digitorum superficialis muscle, and increased the number of myelinated nerve fibers. These findings demonstrate that for finger flexion functional recovery in rats with total brachial plexus injury, transfer of the cC7 root to the lower trunk via the prespinal route is more effective than transfer to the median nerve via subcutaneous tunnel.
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Affiliation(s)
- Ye Jiang
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Li Wang
- Department of Hand Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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31
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Huan KWSJ, Tan JSW, Tan SH, Teoh LC, Yong FC. Restoration of shoulder abduction in brachial plexus avulsion injuries with double neurotization from the spinal accessory nerve: a report of 13 cases. J Hand Surg Eur Vol 2017; 42:700-705. [PMID: 27913804 DOI: 10.1177/1753193416680725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED In upper (C5-C7) and total (C5-T1) root avulsion brachial plexus injury, a method of double neurotization from a single donor spinal accessory nerve to two target nerves (suprascapular nerve and axillary nerve) may be done, leaving donor nerves available for reconstruction procedures to restore other aspects of upper limb function. A mean range of shoulder abduction of 91° (SD 25°) was achieved through this procedure in our study of 13 cases, of which seven cases were C5-C7 root avulsion and six cases were C5-T1 root avulsion brachial plexus injuries. Six of the former group and three of the latter group achieved >90° shoulder abduction. The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- K W S J Huan
- 1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - J S W Tan
- 2 Department of Hand Surgery, Singapore General Hospital, Singapore
| | - S H Tan
- 2 Department of Hand Surgery, Singapore General Hospital, Singapore
| | - L C Teoh
- 3 Department of Hand and Microsurgery, Tan Tock Seng Hospital, Singapore
| | - F C Yong
- 3 Department of Hand and Microsurgery, Tan Tock Seng Hospital, Singapore
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Shimoe T, Doi K, Madura T, Kumar KK, Montales TD, Hattori Y, Sakamoto S, Yukata K, Yoshida M. Analysis of shoulder abduction by dynamic shoulder radiograph following suprascapular nerve repair in brachial plexus injury. J Orthop Sci 2017; 22:840-845. [PMID: 28554714 DOI: 10.1016/j.jos.2017.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 03/15/2017] [Accepted: 05/08/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Suprascapular nerve repair is a widely-prioritized procedure for shoulder reconstruction following brachial plexus injury. Although this procedure only reconstructs glenohumeral joint motion, the standard clinical assessment of shoulder function also includes the scapulothoracic joint contribution. The purpose of this preliminary study was to develop an objective method to accurately analyze shoulder abduction following suprascapular nerve repair in brachial plexus injury patients. METHODS We introduced an objective method to accurately analyze independent shoulder abduction performed by supraspinatus muscle with the help of dynamic shoulder radiography. Antero-posterior radiographs of both shoulders in adduction and maximal active abduction were obtained. Five parameters were measured. They included global abduction, abduction in glenohumeral, scapulothoracic and clavicular joints along with lateral flexion of thoracic spine. Data were analyzed to distinguish glenohumeral joint contribution from that of scapulothoracic motion. The detailed biomechanics of glenohumeral motion were also analyzed in relation to scapulothoracic motion to separately define the contribution of each in global shoulder abduction. RESULTS The test-retest, intra-examiner and inter-examiner reliabilities of the measurements were assessed. Intra-class correlation coefficient, Bland-Altman plots and repeatability coefficients showed excellent reliability for each parameter. The range of glenohumeral abduction showed high correlation to subtraction of the range of scapulothoracic from the range of global abduction. However, not all negative ranges of glenohumeral abduction meant non-recovery after nerve repair, because scapulothoracic motion contributed in parallel but not uniformly to global shoulder motion. CONCLUSION The conventional measurement of shoulder global abduction with goniometer is not an appropriate method to analyze the results of suprascapular nerve repair in brachial plexus palsy patients. We recommend examination of glenohumeral and scapulothoracic motions separately with dynamic shoulder radiographic analysis. With scapulothoracic contribution to the global shoulder motion, the glenohumeral motion can be wrongly assessed.
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Affiliation(s)
- Takashi Shimoe
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan; Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama 641-8510, Japan
| | - Kazuteru Doi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan.
| | - Tomas Madura
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan
| | - Kannan K Kumar
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan
| | - Tristram D Montales
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan
| | - Yasunori Hattori
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan
| | - Sotetsu Sakamoto
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan
| | - Kiminori Yukata
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3 Ogori-Shimogo, Yamaguchi, Yamaguchi 754-0002, Japan
| | - Munehito Yoshida
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama 641-8510, Japan
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Mitchell JJ, Chen C, Liechti DJ, Heare A, Chahla J, Bravman JT. Axillary Nerve Palsy and Deltoid Muscle Atony. JBJS Rev 2017; 5:e1. [DOI: 10.2106/jbjs.rvw.16.00061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Yan JG, Shen FY, Thayer J, Yan Y, LoGiudice J, Matloub H, Sanger J, Zhang LL, Havlik R. Repair of the musculocutaneous nerve using the vagus nerve as donor by helicoid end-to-side technique: an experimental study in rats. J Neurosci Res 2017; 95:2493-2499. [PMID: 28467619 DOI: 10.1002/jnr.24074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/06/2017] [Accepted: 04/06/2017] [Indexed: 12/11/2022]
Abstract
Although several donor nerves can be chosen to repair avulsed brachial plexus nerve injury, available nerves are still limited. The purpose of this study is to validate whether the vagus nerve (VN) can be used as a donor. Eighteen Sprague-Dawley male rats were divided into three groups (n = 6). The right musculocutaneous nerve (McN) was transected with differing subsequent repair. (1) HS-VN group: a saphenous nerve (SN) graft-end was helicoidally wrapped round the VN side (epi-and perineurium was opened) with a 30 ° angle, distal SN end was coapted to the McN with end-to-end repair. (2) EE-PN group: a SN was interpositionally grafted between the transected phrenic nerve (PN) and the McN by end-to-end coaptation. (3) Sham control group: McN was transected and not repaired and postoperative vital signs were checked daily. At three months, electrophysiology, tetanic force, wet biceps muscle weight, and histology were evaluated. Every tested mean value in HS-VN group was significantly greater than the EE-PN or the sham control groups (p < 0.05 or p < 0.005). The mean recovery ratio of regenerated nerve fibers was 96% and, in HS-VN group, the mean recovery ratio of CMAP was 79%. No vital signs changed in any group. There was no statistical difference (p > 0.5) between the mean VN nerve-fiber numbers of the segments proximal (2237 ± 134) and distal (2150 ± 156) to the VN graft-attachment site. Histological analysis revealed no axon injury or intraneural scarring at any point along the VN. This study demonstrated that VN is a practical and reliable donor nerve for end-to-side nerve transfer. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Ji-Geng Yan
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA
| | - Feng-Yi Shen
- Froedtert Health-Community Memorial Hospital, Medical College of Wisconsin Milwaukee, WI, 53226, USA
| | - Jacob Thayer
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA
| | - Yuhui Yan
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA
| | - John LoGiudice
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA
| | - Hani Matloub
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA
| | - James Sanger
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA.,Division of Plastic Surgery, Department of Surgery, Zablocki VA Medical Center, Milwaukee, WI 53295
| | - Lin-Ling Zhang
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA
| | - Robert Havlik
- Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin Milwaukee, Wisconsin, 53226, USA
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Bhandari PS, Sadhotra LP, Bhargava P, Bath AS, Mukherjee MK, Bhatti TS, Maurya S. Multiple nerve transfers for the reanimation of shoulder and elbow functions in irreparable C5, C6 and upper truncal lesions of the brachial plexus. INDIAN JOURNAL OF NEUROTRAUMA 2017. [DOI: 10.1016/s0973-0508(08)80008-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AbstractIn irreparable C5, C6 spinal nerve and upper truncal injuries the proximal root stumps are not available for grafting, hence repair is based on nerve transfer or neurotization. Between Feb 2004 and May 2006, 23 patients with irreparable C5, C6 or upper truncal injuries of the Brachial Plexus underwent multiple nerve transfers to restore the shoulder and elbow functions. Most of them (16 patients) sustained injury following motor cycle accidents. The average denervation period was 5.3 months. Shoulder function was restored by transfer of distal part of spinal accessory nerve to suprascapular nerve, and transfer of radial nerve branch to long head of triceps to the anterior branch of axillary nerve. Elbow function was restored by transfers of ulnar and median nerve fascicles to the biceps and brachialis motor branches of musculocutaneous nerve. All patients recovered shoulder abduction and external rotation; 7 scored M4 and 16 scored M3. Range of abduction averaged 1230(range, 800-1700). Full elbow flexion was restored in all 23 patients; 15 scored M4 and 8 scored M3. Patients with excellent results could lift 5 kgs of weight. Selective nerve transfers close to the target muscle provide an early and good return of functions. There is negligible morbidity in donor nerves. These intraplexal transfers are suitable in all cases of upper brachial plexus injuries.
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Tzou CH, Lu CYJ, Chang TNJ, Chuang DCC. Can an injured nerve be used as a donor nerve for distal nerve transfer?-An experimental study in rats. Microsurgery 2017; 37:647-654. [PMID: 28207955 DOI: 10.1002/micr.30153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 12/01/2016] [Accepted: 12/16/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Distal nerve transfer has proven efficacy. The purpose of this study was to investigate if an injured nerve can be used as a donor nerve for transfer, and to determine the threshold of injury. MATERIALS AND METHODS Rat's left ulnar-nerves in the axilla with different degrees of injury were selected as the donor nerves for transfer, and the musculocutaneous-nerves the target nerves for being re-innervated. Six rats each served as positive and negative controls: Group A, intact ulnar-nerve transfer; and Group E, the ulnar-nerve was cut but no transfer. Ten rats each were assigned to Group B to Group D with 25%, 50%, and 75% transected ulnar-nerve, respectively and all were transferred to the musculocutaneous-nerve. After a 12-week recovery period, outcomes were evaluated. RESULTS Biceps muscle weight measurements showed all experimental groups-D 0.28 ± 0.02 g/72%, C 0.28 ± 0.03 g/73%, B 0.29 ± 0.04 g/74%, and A 0.29 ± 0.04 g/80%-were lighter than group H 0.36 ± 0.04 g, which were all statistically significant (P < 0.001). Muscle tetanus contraction force measurements were the lowest in group D35 ± 8.6 g/69%. Groups C and B measured 41 ± 8.5 g/75% and 40 ± 2.2 g/77% and group A 41 ± 9.4 g/95%, respectively. Group H showed muscle contraction force of 52 ± 7.2 g, which was statistically significant when compared to experimental groups (P < 0.05-0.001). EMG measurements of the biceps muscles showed: group D was 3.6 ± 0.7 mV/69%, group C was 3.6 ± 0.6 mV/75%, and group B was 4.2 mV ± 0.7/81%. Group H was5.1 ± 0.7 mV and statistically significant different when compared with experimental groups (P < 0.05-0.001).Axon counts of healthy ulnar-nerve (Group H) were 1849 ± 362. Axon counts of the injured ulnar-nerve were in group B 1447 ± 579/78%, group C 1051 ± 367/57% and group D 567 ± 230/31%. CONCLUSION The donor nerve should be healthy in order to provide optimal result. A big nerve (e.g., ulnar nerve) but injured with at least 75% axon spared is still potentially effective for transfer. In contrast, a small nerve (e.g., intercostal nerve) once injured with 75%axon spared would be considered a suboptimal donor nerve.
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Affiliation(s)
- Chieh-Han Tzou
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Chuieng-Yi Johnny Lu
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Affiliation(s)
- Han-Vit Kang
- Department of Orthopedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Joo-Yup Lee
- Department of Orthopedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
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Restoration of elbow and hand function in total brachial plexus palsy with intercostal nerves and C5 root neurotization. Results in 21 patients. HAND SURGERY & REHABILITATION 2016; 35:283-287. [PMID: 27781993 DOI: 10.1016/j.hansur.2016.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 05/05/2016] [Accepted: 05/17/2016] [Indexed: 01/09/2023]
Abstract
Consensus opinion is that active movement of the elbow is a priority in the surgical treatment of total brachial plexus injuries. But the indications and neurotization techniques used to restore motor function of the hand are the subject of discussion. The aim of this retrospective study was to evaluate, in adult patients with complete post-traumatic paralysis of the brachial plexus, the functional results of neurotization of four intercostal nerves on the musculocutaneous nerve and grafting of the C5 root by one strand on the nerve to the long head of triceps and three strands on the medial component of the median nerve. The cohort included 21 patients (mean age 21years). The average time between the trauma and surgical treatment was 4.8months. At a mean follow-up of 22months, 67% of patients achieved≥M3 elbow flexion, and 62% achieved≥M3 active elbow extension. Of the patients who had the required follow-up of 2years to assess motor recovery of the median nerve, 40% achieved function≥M3. Based on our results, use of the C5 root is suitable for surgically restoring elbow extension and finger flexion.
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Dual Nerve Transfers for Restoration of Shoulder Function After Brachial Plexus Avulsion Injury. Ann Plast Surg 2016; 76:668-73. [DOI: 10.1097/sap.0000000000000747] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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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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Potter SM, Ferris SI. Vascularized Thoracodorsal to Suprascapular Nerve Transfer, a Novel Technique to Restore Shoulder Function in Partial Brachial Plexopathy. Front Surg 2016; 3:17. [PMID: 27014699 PMCID: PMC4789804 DOI: 10.3389/fsurg.2016.00017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/25/2016] [Indexed: 11/13/2022] Open
Abstract
We describe the clinical outcome of a novel nerve transfer to restore active shoulder motion in upper brachial plexus injury. The thoracodorsal nerve (TDN) was successfully used as a vascularized donor nerve to neurotize to the suprascapular nerve (SSN) in a patient with limited donor nerve availability. At 4 years follow-up, he had regained useful external rotation of the injured limb, with no significant donor site morbidity. Shoulder abduction return was less impressive, however, and reasons for this are discussed. We provide a comprehensive review of the literature on this topic and a subsequent discussion on the details of this novel technique. This is the first reported case of TDN to SSN transfer, and also the first reported case of a vascularized TDN transfer in the English language literature. We advocate direct thoracodorsal to SSN transfer as a valid surgical option for the restoration of shoulder function in patients with partial brachial plexus avulsion, when conventional nerve donors are unavailable.
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Affiliation(s)
- Shirley M Potter
- Victorian Plastic Surgery Unit, St Vincent's Private Hospital, Melbourne, VIC, Australia; The Alfred Hospital, Melbourne, VIC, Australia
| | - Scott I Ferris
- Victorian Plastic Surgery Unit, St Vincent's Private Hospital, Melbourne, VIC, Australia; The Alfred Hospital, Melbourne, VIC, Australia
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Socolovsky M, Costales JR, Paez MD, Nizzo G, Valbuena S, Varone E. Obstetric brachial plexus palsy: reviewing the literature comparing the results of primary versus secondary surgery. Childs Nerv Syst 2016; 32:415-25. [PMID: 26615411 DOI: 10.1007/s00381-015-2971-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 11/27/2022]
Abstract
Obstetric brachial plexus injuries (OBPP) are a relatively common stretch injury of the brachial plexus that occurs during delivery. Roughly 30 % of patients will not recover completely and will need a surgical repair. Two main treatment strategies have been used: primary surgery, consisting in exploring and reconstructing the affected portions of the brachial plexus within the first few months of the patient's life, and secondary procedures that include tendon or muscle transfers, osteotomies, and other orthopedic techniques. Secondary procedures can be done as the only surgical treatment of OBPP or after primary surgery, in order to minimize any residual deficits. Two things are crucial to achieving a good outcome: (1) the appropriate selection of patients, to separate those who will spontaneously recover from those who will recover only partially or not at all; and (2) a good surgical technique. The objective of the present review is to assess the published literature concerning certain controversial issues in OBPP, especially in terms of the true current state of primary and secondary procedures, their results, and the respective roles each plays in modern-day treatment of this complex pathology. Considerable published evidence compiled over decades of surgical experience favors primary nerve surgery as the initial therapeutic step in patients who do not recover spontaneously, followed by secondary surgeries for further functional improvement. As described in this review, the results of such treatment can greatly ameliorate function in affected limbs. For best results, multi-disciplinary teams should treat these patients.
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Affiliation(s)
- Mariano Socolovsky
- Department of Neurosurgery, Peripheral Nerve & Brachial Plexus Unit, University of Buenos Aires School of Medicine, La Pampa 1175 5 A, 1428, Buenos Aires, Argentina.
| | | | | | - Gustavo Nizzo
- Department of Orthopedic Surgery, Peripheral Nerve & Brachial Plexus Unit, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Sebastian Valbuena
- Department of Orthopedic Surgery, Hospital de Alta Complejidad en Red El Cruce, Buenos Aires, Argentina
| | - Ernesto Varone
- Department of Orthopedic Surgery, Hospital Ricardo Gutierrez, Buenos Aires, Argentina
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Abstract
Nerve injuries above the elbow are associated with a poor prognosis, even with prompt repair and appropriate rehabilitation. The past 2 decades have seen the development of numerous nerve transfer techniques, by which a denervated peripheral target is reinnervated by a healthy donor nerve. Nerve transfers are indicated in proximal brachial plexus injuries where grafting is not possible or in proximal injuries of peripheral nerves with long reinnervation distances. Nerve transfers represent a revolution in peripheral nerve surgery and offer the potential for superior functional recovery in severe nerve injuries. However, the techniques have not been universally adopted due in part to a misconception that nerve transfers can only be understood and performed by superspecialists. Nerve transfer procedures are not technically difficult and require no specialized equipment. Numerous transfers have been described, but there are a handful of transfers for which there is strong clinical evidence. To restore shoulder abduction and external rotation in upper trunk brachial plexus injury, the key transfers are the spinal accessory to suprascapular nerve and the medial triceps branch to axillary nerve. For elbow flexion, the flexor carpi ulnaris branch of ulnar nerve to the biceps and brachialis branches of the musculocutaneous nerve is the key transfer. For ulnar intrinsic function, the distal anterior interosseous nerve to ulnar motor branch transfer has yielded excellent functional results. Nerve transfers form a therapeutic triad with traditional tendon transfers and functional motor unit rehabilitation which, when applied appropriately, can yield excellent functional results in complex nerve injuries. Nerve transfers are a powerful yet underused tool for proximal nerve injuries, which offer hope for traditionally discouraging injuries.
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Satbhai NG, Doi K, Hattori Y, Sakamoto S. Functional outcome and quality of life after traumatic total brachial plexus injury treated by nerve transfer or single/double free muscle transfers. Bone Joint J 2016; 98-B:209-17. [DOI: 10.1302/0301-620x.98b2.35101] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Between 2002 and 2011, 81 patients with a traumatic total brachial plexus injury underwent reconstruction by double free muscle transfer (DFMT, 47 cases), single muscle transfer (SMT, 16 cases) or nerve transfers (NT, 18 cases). Methods They were evaluated for functional outcome and quality of life (QoL) using the Disability of Arm, Shoulder and Hand questionnaire, both pre- and post-operatively. The three groups were compared and followed-up for at least 24 months. Results The mean shoulder abduction and flexion were comparable in all groups, but external rotation was significantly better in the DFMT group as were range and quantitative power of elbow flexion. Patients who had undergone DFMT had reasonable total active finger movement and hook grip strength. All groups showed improvement in function at a level greater than a minimum clinically important difference. The DFMT group showed the greatest improvement. Discussion Patients in the DFMT group had a better functional outcome and QoL recovery than those in the NT and SMT groups. Take home message: Double free muscle transfer procedure is capable of restoring maximum function in patients of total brachial plexus palsy. Cite this article: Bone Joint J 2016;97-B:209–17.
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Affiliation(s)
- N. G. Satbhai
- Ogori Daiichi General Hospital, 862-3, Shimogo, Ogori, Yamaguchi-City, Yamaguchi-Prefecture, 754-0002, Japan
| | - K. Doi
- Ogori Daiichi General Hospital, 862-3, Shimogo, Ogori, Yamaguchi-City, Yamaguchi-Prefecture, 754-0002, Japan
| | - Y. Hattori
- Ogori Daiichi General Hospital, 862-3, Shimogo, Ogori, Yamaguchi-City, Yamaguchi-Prefecture, 754-0002, Japan
| | - S. Sakamoto
- Ogori Daiichi General Hospital, 862-3, Shimogo, Ogori, Yamaguchi-City, Yamaguchi-Prefecture, 754-0002, Japan
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Abstract
Abstract
Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.
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Affiliation(s)
- Wilson Z. Ray
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jason Chang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ammar Hawasli
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas J. Wilson
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lynda Yang
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
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Clinical aspects of patients with traumatic lesions of the brachial plexus following surgical treatment. Rev Bras Ortop 2015; 50:556-61. [PMID: 26535203 PMCID: PMC4610988 DOI: 10.1016/j.rboe.2015.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 10/23/2014] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate sociodemographic and clinical aspects of patients undergoing operations due to traumatic lesions of the brachial plexus. Method This was a retrospective study in which the medical files of a convenience sample of 48 patients operated between 2000 and 2010 were reviewed. The following were evaluated: (1) range of motion (ROM) of the shoulder, elbow and wrist/hand, in degrees; (2) grade of strength of the shoulder, elbow and wrist/hand; (3) sensitivity; and (4) visual analogue scale (VAS) (from 0 to 10). The Student's t, chi-square, Friedman, Wilcoxon and Kruskal–Wallis tests were used (p < 0.05). Results The patients’ mean age was 30.6 years; 60.4% of them had suffered motorcycle accidents and 52.1%, multiple trauma. The mean length of time until surgery was 8.7 months (range: 2–48). Thirty-one patients (64.6%) presented complete rupture of the plexus. The frequent operation was neurosurgery in 39 cases (81.3%). The ROM achieved was ≥30° in 20 patients (41.6%), with a range from 30° to 90° and mean of 73° (p = 0.001). Thirteen (27.1%) already had shoulder strength ≥M3 (p = 0.001). Twenty-seven patients (56.2%) had elbow flexion ≥80°, with a range from 30° to 160° and mean of 80.6° (p < 0.001). Twenty-two had strength ≥M3 (p < 0.001). Twenty-two patients (45.8%) had wrist extension ≥30° starting from flexion of 45°, with a range from 30° to 90° and mean of 70° (p = 0.003). Twenty-seven (56.3%) presented wrist/hand extension strength ≥M3 (p = 0.002). Forty-five (93.8%) had hypoesthesia and three (6.2%) had anesthesia (p = 0.006). The initial VAS was 4.5 (range: 1.0–9.0) and the final VAS was 3.0 (range: 1.0–7.0) (p < 0.001). Conclusion Traumatic lesions of the brachial plexus were more prevalent among young adults (21–40 years), men, people living in urban areas, manual workers and motorcycle accidents, with multiple trauma and total rupture of the plexus. Neurosurgery, with a second procedure consisting of muscle-tendon transfer, was the commonest operation. Surgery for traumatic lesions of the brachial plexus resulted in significant improvement in the ROM and strength of the shoulder, elbow and wrist/hand, improvement of the sensitivity of the limb affected and reduction of the final pain.
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de Moraes FB, Kwae MY, da Silva RP, Porto CC, Magalhães DDP, Paulino MV. Aspectos clínicos de pacientes com lesão traumática do plexo braquial após tratamento cirúrgico. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2015.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Zermeño-Rivera J, Gutiérrez-Amavizca BE. Contralateral Spinal Accessory Nerve Transfer: A New Technique in Panavulsive Brachial Plexus Palsy. Indian J Surg 2015; 77:247-50. [PMID: 26246713 DOI: 10.1007/s12262-013-1020-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 12/03/2013] [Indexed: 11/26/2022] Open
Abstract
Brachial plexus avulsion results from excessive stretching and can occur secondary to motor vehicle accidents, mainly in motorcyclists. In a 28-year-old man with panavulsive brachial plexus palsy, we describe an alternative technique to repair brachial plexus avulsion and to stabilize and preserve shoulder function by transferring the contralateral spinal accessory nerve to the suprascapular nerve. We observed positive clinical and electromyographic results in sternocleidomastoid, trapezius, supraspinatus, infraspinatus, pectoralis, triceps, and biceps, with good outcome and prognosis for shoulder function at 12 months after surgery. This technique provides a unique opportunity for patients suffering from severe brachial plexus injuries and lacking enough donor nerves to obtain shoulder stability and mobility while avoiding bone fusion and preserving functionality of the contralateral shoulder with favorable postoperative outcomes.
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Affiliation(s)
- Jaime Zermeño-Rivera
- Servicio de Cirugía Reconstructiva del Instituto Jalisciense de Cirugía Reconstructiva "Dr. José Guerrerosantos", Federalismo Norte 2022, Guadalupana, 44220 Guadalajara, Jalisco Mexico ; Vida integra, control de diabetes y obesidad, José María Heredia 2964, Col. Prados Providencia, C.P. 44670 Guadalajara, Jalisco Mexico
| | - Bianca Ethel Gutiérrez-Amavizca
- División de Genética, Centro de Investigación Biomédica de Occidente, IMSS; Doctorado en Genética Humana, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Sierra Mojada 800. Col. Independencia, 44340 Guadalajara, Jalisco Mexico
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Socolovsky M, di Masi G, Bonilla G, Paez MD, Robla J, Cabrera CC. The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis. Acta Neurochir (Wien) 2015; 157:1077-86; discussion 1086. [PMID: 25833303 DOI: 10.1007/s00701-015-2387-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Controversy exists surrounding the use of the phrenic nerve for transfer in severe brachial plexus injuries. The objectives of this study are: (1) to present the experience of the authors using the phrenic nerve in a single institution; and (2) to thoroughly review the existing literature to date. METHODS Adult patients with C5-D1 and C5-C8 lesions and a phrenic nerve transfer were retrospectively included. Patients with follow-up shorter than 18 months were excluded. The MRC muscle strength grading system was used to rate the outcome. Clinical repercussions relating to sectioning of the phrenic nerve were studied. An intense rehabilitation program was started after surgery, and compliance to this program was monitored using a previously described scale. Statistical analysis was performed with the obtained data. RESULTS Fifty-one patients were included. The mean time between trauma and surgery was 5.7 months. Three-quarters of the patients had C5-D1, with the remainder C5-C8. Mean post-operative follow-up was 32.5 months A MRC of M4 was achieved in 62.7% patients, M3 21.6%, M2 in 3.9%, and M1 in 11.8%. The only significant differences between the two groups were in graft length (9.8 vs. 15.1 cm, p = 0.01); and in the rehabilitation compliance score (2.86 vs. 2.00, p = 0.01). CONCLUSIONS Results of phrenic nerve transfer are predictable and good, especially if the grafts are short and the rehabilitation is adequate. It may adversely affect respiratory function tests, but this rarely correlates clinically. Contraindications to the use of the phrenic nerve exist and should be respected.
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Liu Y, Xu XC, Zou Y, Li SR, Zhang B, Wang Y. Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics. Neural Regen Res 2015; 10:328-33. [PMID: 25883637 PMCID: PMC4392686 DOI: 10.4103/1673-5374.152388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2014] [Indexed: 11/04/2022] Open
Abstract
Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering 'excellent' and 'good' muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.
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Affiliation(s)
- Ying Liu
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Xun-Cheng Xu
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Yi Zou
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Su-Rong Li
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Bin Zhang
- Department of Orthopedics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Yue Wang
- Department of Orthopedics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
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