Nerve transfers for severe brachial plexus injuries: a review

Outcomes of Oberlin Transfer in Elderly Patients: A Case Series

OBJECTIVE

A case series analysis was performed of upper brachial plexus injuries (BPIs) from low-impact trauma in patients ≥60 years old to assess the effectiveness of nerve transfers, particularly the Oberlin technique, in restoring elbow flexion and to refine clinical decision making for managing traumatic BPIs in this age group.

METHODS

Between 2013 and 2024, 11 patients aged 60-72 with traumatic upper BPIs underwent Oberlin technique for elbow flexion; all were evaluated with consistent postsurgical criteria.

RESULTS

Trauma mechanisms included falls (55%), direct trauma (27%), knife wounds (9%), and stretching (9%), with no high-impact trauma cases. Injuries predominantly affected the right side (55%). Elbow flexion strength was assessed using the British Medical Research Council scale. Positive Tinel sign was present in 73% of patients, all reporting pain ranging from mild to severe. At 1 year postsurgery, 64% achieved M4 elbow flexion, 27% achieved M3, and 9% achieved M1 after 4 months. Patients >65 who received surgery within 6 months of injury showed better outcomes except for 1 case. No ulnar nerve deficits were observed. Following surgery, 36% experienced no pain, whereas 64% reported mild pain. Additionally, 64% underwent further nerve transfers to restore shoulder function (spinal accessory nerve to suprascapular nerve), and 18% underwent the Somsakprocedure for deltoid function.

CONCLUSIONS

Positive outcomes were achieved with the Oberlin technique in patients >60 with upper BPIs from low-energy trauma. However, delayed surgery, significant atrophy, and low testosterone levels may affect results. Evaluation of each patient's medical history is crucial before performing this procedure.

The Physiotherapy Management of Postoperative Mid-shaft Clavicular Fracture With Brachial Plexus Injury: A Case Report

Traumatic brachial plexus injury (BPI) is a debilitating condition predominantly affecting young males, often resulting from traction or direct injuries. Due to the complicated neuronal network, the damage is often classified as preganglionic or postganglionic injuries. It includes upper-limb mobility impairments as well as reduced muscular strength and sensitivity. We discuss a case of a 30-year-old female who suffered a displaced mid-shaft clavicular fracture and BPI after a road traffic collision. The patient experienced significant pain, restricted movement, and sensory and motor loss in her left arm. Imaging studies revealed additional complications, including epidural collection and pseudomeningoceles. She underwent open reduction and internal fixation of the clavicle, followed by a structured rehabilitation program focusing on pain management, muscle re-education, and functional recovery. This case highlights the complexity of managing clavicular fractures with concurrent BPI, requiring a multidisciplinary approach involving imaging, surgical intervention, and comprehensive physiotherapy for optimal recovery and functional restoration. Rehabilitation strategies were employed to address the diverse symptoms, including multi-sensory strategies, sensory re-education, graded motor imagery rehabilitation, and gradual restoration of upper extremity (UE) range, strength, and endurance and to develop neuromuscular control. Effective management of clavicular fractures with BPI requires early diagnosis, surgical intervention, and structured rehabilitation to improve functional outcomes and quality of life.

Brief Electrical Stimulation Promotes Recovery after Surgical Repair of Injured Peripheral Nerves

Injured peripheral nerves regenerate their axons in contrast to those in the central nervous system. Yet, functional recovery after surgical repair is often disappointing. The basis for poor recovery is progressive deterioration with time and distance of the growth capacity of the neurons that lose their contact with targets (chronic axotomy) and the growth support of the chronically denervated Schwann cells (SC) in the distal nerve stumps. Nonetheless, chronically denervated atrophic muscle retains the capacity for reinnervation. Declining electrical activity of motoneurons accompanies the progressive fall in axotomized neuronal and denervated SC expression of regeneration-associated-genes and declining regenerative success. Reduced motoneuronal activity is due to the withdrawal of synaptic contacts from the soma. Exogenous neurotrophic factors that promote nerve regeneration can replace the endogenous factors whose expression declines with time. But the profuse axonal outgrowth they provoke and the difficulties in their delivery hinder their efficacy. Brief (1 h) low-frequency (20 Hz) electrical stimulation (ES) proximal to the injury site promotes the expression of endogenous growth factors and, in turn, dramatically accelerates axon outgrowth and target reinnervation. The latter ES effect has been demonstrated in both rats and humans. A conditioning ES of intact nerve days prior to nerve injury increases axonal outgrowth and regeneration rate. Thereby, this form of ES is amenable for nerve transfer surgeries and end-to-side neurorrhaphies. However, additional surgery for applying the required electrodes may be a hurdle. ES is applicable in all surgeries with excellent outcomes.

Motor and sensory nerve transfers in the lower extremity: Systematic review of current reconstructive possibilities

BACKGROUND

Peripheral nerve injuries (PNI) are predominantly treated by anatomical repair or reconstruction with autologous nerve grafts or allografts. Motor nerve transfers for PNI in the upper extremity are well established; however, this technique is not yet widely used in the lower extremity. This literature review presents an overview of the current options and postoperative results for nerve transfers as a treatment for nerve injury in the lower extremity.

METHODS

A systematic search in PubMed and Embase databases was performed. Full-text English articles describing surgical procedures and postoperative outcomes of nerve transfers in the lower extremity were included. The primary outcome was postoperative muscle strength measured using the British Medical Research Council (MRC) scale, with MRC> 3 considered good and postoperative return of sensation reported according to the modified Highet classification.

RESULTS

A total of 36 articles for motor nerve transfer and 7 for sensory nerve transfer were included. Sixteen articles described motor nerve transfers for treating peroneal nerve injury, 17 for femoral nerve injury, 2 for tibial nerve injury, and one for obturator nerve injury. Transfers of multiple branches to restore deep peroneal nerve function led to a good outcome in 58% of patients and 43% when a single branch was used as a donor. The transfer of multiple branches for femoral nerve or obturator nerve repair was performed in all reported patients with a good outcome.

CONCLUSIONS

The transfer of motor nerves for the recovery of PNI is a feasible technique with relatively low risks and great benefits. The correct indication, timing, and surgical technique are essential for optimizing results.

Examination of Upper Extremity Length Discrepancy in Patients with Obstetric Brachial Plexus Paralysis

Since the natural course of obstetric brachial plexus palsy is variable, several problems are encountered. One important question, in considering patients with OBPP under observation in outpatient clinical settings, is whether children will have length discrepancies in their arms. The aim of this study was to determine differences in the length of the affected extremity, in comparison to the opposite upper extremity. As such, 45 patients, aged 6 months to 18 years, with unilateral brachial plexus palsy developed due to obstetric reasons, were included in the study. Affected and healthy side humerus, ulna, radius, 2nd metacarpal and 5th metacarpal lengths were evaluated according to gender, age, side, Narakas classification, primary and secondary surgery. Statistically significant differences were found in the change rates of affected/healthy humerus, radius, 2nd metacarpal and 5th metacarpal lengths according to age (93%, 95%, 92%, 90% and 90%, respectively). Affected/healthy change rates of ulna, radius, 2nd metacarpal and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to the Narakas classification variable (94%, 92%, 95%, 94% and 94%, respectively). There were no statistically significant differences in the ratios of affected/healthy change in the lengths of the humerus, ulna, radius and 5th metacarpal compared to the primary surgery (p > 0.05). The ratios of affected/healthy change in ulna, radius and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to secondary surgeries (93%, 91%, 91% and 92%, respectively). Joint and bone deformities and bone shortening were observed after changes that occurred in the postnatal and growing periods due to obstetric brachial plexus palsy. Every increase in function to be gained in the upper extremity musculature was also potentially able to reduce problems, such as shortness.

Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy

OBJECTIVE

Cervical nerve 5 palsy can occur following surgery for cervical spine pathology. The prognosis of C5 palsy is generally favorable, and most patients recover useful function. However, some patients do not recover useful strength. Nerve transfers are a potential effective treatment of postoperative severe C5 palsy. This study aimed to further delineate the natural history of recovery from postoperative C5 palsy, determine whether lack of recovery at specific time points predicts poor recovery prognosis, and thereby determine a reasonable time point for referral to a complex peripheral nerve specialist.

METHODS

The authors conducted a retrospective review of 72 patients who underwent surgery for cervical spondylosis and stenosis complicated by C5 palsy. Medical Research Council (MRC) motor strength grades were recorded preoperatively; immediately postoperatively; at discharge; and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Univariate and multivariate logistic regression models were used to identify demographic and clinical risk factors associated with recovery of useful strength after severe C5 palsy.

RESULTS

The mean patient age was 62.5 years, and 36.1% of patients were female. Thirty patients (41.7%) experienced severe C5 palsy with less than antigravity strength (MRC grade 2 or less) at discharge. Twenty-one (70%) of these patients recovered useful strength (MRC grade 3 or greater) at 12 months postoperatively, and 9 patients (30%) did not recover useful strength at 12 months. Of those patients with persistent severe C5 palsy at 3 months postoperatively, 50% recovered useful strength at 12 months. Of those patients with persistent severe C5 palsy at 6 months postoperatively, 25% recovered useful strength at 12 months. No patient with MRC grade 0 or 1 strength at 6 months postoperatively recovered useful strength. A history of diabetes was associated with the occurrence of severe C5 palsy. On multivariate analysis, female sex was associated with recovery of useful strength.

CONCLUSIONS

Most patients with severe C5 palsy recover useful strength in their C5 myotome within 12 months of onset. However, at 3 months postoperatively, patients with persistent severe C5 palsy had only a 50% chance of recovering useful strength by 12 months. Lack of recovery of useful strength at 3 months postoperatively is a reasonable time point for referral to a complex peripheral nerve center to establish care and to determine candidacy for nerve transfer surgery if severe C5 palsy persists.

The Outcome of Neurotization of Brachial Plexus Injury in a Tertiary Centre: A Nine-Year Review

Introduction: In neurotization or nerve transfer, a healthy but less valuable nerve is transferred to re-innervate a more important motor territory that has lost its innervation through irreparable damage to its nerve.

Methodology: In this study, the outcomes of surgery were analyzed in relation to the muscle strength, range of motion of the upper limb, and functional outcome. The results were analyzed in 19 patients who were operated on between 2008 and 2016 with adequate follow-up. 

Result: Of the 19 patients (15 complete brachial plexus injuries and four incomplete brachial plexus injuries), 13 patients (68%) recovered partial function after the neurotization surgery. Shoulder abduction and elbow flexion were achieved in 11 patients (58%). Six of the 10 patients (32%) in complete pre-ganglionic brachial plexus injury had recovered partial function. Whereas five of the six patients (83%) in complete post-ganglionic had recovered partial function. In incomplete upper trunk brachial plexus injury, three of the four patients (75%) recovered some function after the neurotization surgery.

Conclusion: Nerve transfer is an effective treatment option to restore the function of the affected upper limb. Neurotization without intervening nerve graft shows better recovery. Earlier surgical intervention at a younger age can yield better outcomes.

Feasibility of the Oberlin Procedure in Late Presentation Cases of C5-C6 and C5-C7 Brachial Plexus Injuries in Adults

Background: Oberlin et al presented a new technique for nerve transfer that completely changed the prognosis of patients with brachial plexus injury. Currently, most of the literature addresses cases submitted to early surgical intervention, before 12 months from injury, showing consistent good results. The aim of this study was to evaluate the feasibility of the Oberlin procedure in late presentation cases (≥12 months), comparing the elbow flexion strength with patients operated earlier. Methods: We retrospectively reviewed 49 patients with partial brachial plexus injuries submitted to the Oberlin procedure. They were divided into 2 groups. Group A included 39 patients operated with <12 months of injury. The mean postoperative follow-up was 22.53 months. The interval from injury to surgery varied from 4 to 11 months (±8.45 months). Group B included 10 patients with surgery ≥12 months after injury. The mean postoperative follow-up was 32 months. The interval from injury to surgery ranged from 12 to 19 months (±15.4 months). Patients were evaluated monthly after surgery and the elbow flexion strength was measured using the British Medical Research Council scale. Results: In Group A, 24 patients presented with either good (M3) or excellent (M4) elbow flexion strength. In Group B, 9 patients presented with either good (M3) or excellent (M4) elbow flexion strength. A significant difference was not seen in the postoperative elbow flexion strength among the 2 groups. Conclusion: Biceps reinnervation with the Oberlin procedure is still feasible and should be attempted after more than 12 months of injury in partial brachial plexus injuries.

Comparison of Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Versus Nerve Grafting for Neonatal Brachial Plexus Injury

Neonatal brachial plexus injuries may cause critical limitations of upper extremity function. The optimal surgical approach to address neonatal brachial plexus injuries has not been defined. In this systematic review, we compare clinical results after spinal accessory to suprascapular nerve transfer and nerve graft techniques among patients with neonatal brachial plexus injury. [Orthopedics. 2022;45(1):7-12.].

Brachial plexus anatomy in the miniature swine as compared to human

Brachial plexus injury (BPI) occurs when the brachial plexus is compressed, stretched, or avulsed. Although rodents are commonly used to study BPI, these models poorly mimic human BPI due to the discrepancy in size. The objective of this study was to compare the brachial plexus between human and Wisconsin Miniature SwineTM (WMSTM ), which are approximately the weight of an average human (68-91 kg), to determine if swine would be a suitable model for studying BPI mechanisms and treatments. To analyze the gross anatomy, WMS brachial plexuses were dissected both anteriorly and posteriorly. For histological analysis, sections from various nerves of human and WMS brachial plexuses were fixed in 2.5% glutaraldehyde, and postfixed with 2% osmium tetroxide. Subsequently paraffin sections were counter-stained with Masson's Trichrome. Gross anatomy revealed that the separation into three trunks and three cords is significantly less developed in the swine than in human. In swine, it takes the form of upper, middle, and lower systems with ventral and dorsal components. Histological evaluation of selected nerves revealed differences in nerve trunk diameters and the number of myelinated axons in the two species. The WMS had significantly fewer myelinated axons than humans in median (p = 0.0049), ulnar (p = 0.0002), and musculocutaneous nerves (p = 0.0454). The higher number of myelinated axons in these nerves for humans is expected because there is a high demand of fine motor and sensory functions in the human hand. Due to the stronger shoulder girdle muscles in WMS, the WMS suprascapular and axillary nerves were larger than in human. Overall, the WMS brachial plexus is similar in size and origin to human making them a very good model to study BPI. Future studies analyzing the effects of BPI in WMS should be conducted.

Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions

Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.

Motion Analytics of Trapezius Muscle Activity in an 18-Year-Old Female with Extended Upper Brachial Plexus Birth Palsy

Background  The trapezius muscle is often utilized as a muscle or nerve donor for repairing shoulder function in those with brachial plexus birth palsy (BPBP). To evaluate the native role of the trapezius in the affected limb, we demonstrate use of the Motion Browser, a novel visual analytics system to assess an adolescent with BPBP.

Method  An 18-year-old female with extended upper trunk (C5–6–7) BPBP underwent bilateral upper extremity three-dimensional motion analysis with Motion Browser. Surface electromyography (EMG) from eight muscles in each limb which was recorded during six upper extremity movements, distinguishing between upper trapezius (UT) and lower trapezius (LT). The Motion Browser calculated active range of motion (AROM), compiled the EMG data into measures of muscle activity, and displayed the results in charts.

Results  All movements, excluding shoulder abduction, had similar AROM in affected and unaffected limbs. In the unaffected limb, LT was more active in proximal movements of shoulder abduction, and shoulder external and internal rotations. In the affected limb, LT was more active in distal movements of forearm pronation and supination; UT was more active in shoulder abduction.

Conclusion  In this female with BPBP, Motion Browser demonstrated that the native LT in the affected limb contributed to distal movements. Her results suggest that sacrificing her trapezius as a muscle or nerve donor may affect her distal functionality. Clinicians should exercise caution when considering nerve transfers in children with BPBP and consider individualized assessment of functionality before pursuing surgery.

Indications for amputation after traumatic brachial plexus injury in adults: Case report and review of new prosthetic technologies

Hand amputation can be discussed after traumatic brachial plexus injury when the patient's hand is non-functional, painful and/or insensitive. That indication is more common in English-speaking countries than in European or Latin countries. New prostheses are now on the market and can be used after hand amputation to improve the functional prognosis in well-selected patients. A 26-year-old male was involved in a road accident in January 2016. He had a traumatic brachial plexus injury and underwent nerve surgery to restore the biceps brachii and triceps brachii. One year after nerve transfer, his hand was insensitive and non- functional. After multidisciplinary consultation, it was decided to amputate his hand to replace it with a myoelectric prosthesis. Shoulder subluxation pain and complications associated with an insensitive and heavy arm were improved after hand amputation. Functional outcomes were improved with this revolutionary myoelectric prosthesis technique. The patient was able to use his prosthesis for many daily activities. Selective amputation indications after traumatic brachial plexus injury are a heavy and stiff arm with shoulder subluxation pain and an unusable claw hand. The patient's motivation must be high.

Roles of preoperative and early postoperative electrodiagnosis in brachial plexus injury patients undergoing nerve transfer operations: retrospective feasibility study

Objective

The purpose of this retrospective observational study was to assess the feasibility of electrodiagnostic parameters, perioperatively, and to discover optimal values as prognostic factors for patients with brachial plexus injury undergoing nerve transfer operations.

Methods

We retrospectively reviewed the records of 11 patients who underwent nerve transfer surgery. The patients underwent perioperative electrodiagnosis (EDX) before and approximately 6 months after surgery. We evaluated the compound muscle action potential (CMAP) ratio, motor unit recruitment, and their interval changes. To evaluate motor strength, we used the Medical Research Council (MRC) grade, 6 and 12 months after surgery. We evaluated the relationships between improved CMAP ratio, and motor unit recruitment and MRC grade changes 6 and 12 months postoperatively.

Results

All parameters increased significantly after surgery. The CMAP ratio improvement 6 months after surgery correlated with the MRC grade change from baseline to 12 months, with a correlation coefficient of 0.813.

Conclusion

EDX parameters improved significantly postoperatively, and the CMAP ratio improvement 6 months after surgery correlated with the clinical outcomes at 1 year. The results of perioperative EDX might help establish long-term treatment plans for patients who undergo nerve transfer surgery.

Five Reliable Nerve Transfers for the Treatment of Isolated Upper Extremity Nerve Injuries

LEARNING OBJECTIVES

After studying this article and accompanying videos, the participant should be able to: 1. Understand and apply the principles of nerve transfer surgery for nerve injuries. 2. Discuss important considerations when performing nerve transfers, such as aspects of surgical technique and perioperative decision-making. 3. Understand indications for end-to-end versus supercharged reverse end-to-side nerve transfers. 4. Understand an algorithm for treating nerve injuries to include the indications and surgical techniques of five nerve transfers commonly performed for the treatment of isolated upper extremity nerve injuries. 5. Understand the outcomes and postoperative management of the discussed nerve transfers.

SUMMARY

Nerve transfers are gaining wide acceptance because of their superior results in the management of many nerve injuries of the upper extremity. This article presents five nerve transfers for the treatment of isolated nerve injuries in the authors' upper extremity nerve practice that offer reliable results. Indications, surgical techniques, outcomes, and postoperative management are reviewed. To maximize functional outcomes in patients with nerve injuries, the treatment should be individualized to the patient, and the principles for nerve transfers as described herein should be considered.

Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers

Traumatic upper trunk brachial plexopathy, also known as a stinger or burner, is the most common upper extremity neurologic injury among athletes and most commonly involves the upper trunk. Recent studies have shown the incidence of both acute and recurrent injuries to be higher in patients with certain anatomic changes in the cervical spine. In addition, despite modern awareness, tackling techniques, and protective equipment, some think the incidence to be slowly on the rise in contact athletes. The severity of neurologic injury varies widely but usually does not result in significant loss of playing time or permanent neurologic deficits if appropriate management is undertaken. Timely diagnosis allows implementation of means to minimize the risk of recurrent injury. It is important for treating physicians to understand the pathogenesis, evaluation, and acute and long-term management of stingers to improve recovery and minimize chronic sequela.

Combination Treatment With Exogenous GDNF and Fetal Spinal Cord Cells Results in Better Motoneuron Survival and Functional Recovery After Avulsion Injury With Delayed Root Reimplantation

When spinal roots are torn off from the spinal cord, both the peripheral and central nervous system get damaged. As the motoneurons lose their axons, they start to die rapidly, whereas target muscles atrophy due to the denervation. In this kind of complicated injury, different processes need to be targeted in the search for the best treatment strategy. In this study, we tested glial cell-derived neurotrophic factor (GDNF) treatment and fetal lumbar cell transplantation for their effectiveness to prevent motoneuron death and muscle atrophy after the spinal root avulsion and delayed reimplantation. Application of exogenous GDNF to injured spinal cord greatly prevented the motoneuron death and enhanced the regeneration and axonal sprouting, whereas no effect was seen on the functional recovery. In contrast, cell transplantation into the distal nerve did not affect the host motoneurons but instead mitigated the muscle atrophy. The combination of GDNF and cell graft reunited the positive effects resulting in better functional recovery and could therefore be considered as a promising strategy for nerve and spinal cord injuries that involve the avulsion of spinal roots.

Testing the effectiveness and the contribution of experimental supercharge (reversed) end-to-side nerve transfer

OBJECTIVE

Supercharge end-to-side (SETS) transfer, also referred to as reverse end-to-side transfer, distal to severe nerve compression neuropathy or in-continuity nerve injury is gaining clinical popularity despite questions about its effectiveness. Here, the authors examined SETS distal to experimental neuroma in-continuity (NIC) injuries for efficacy in enhancing neuronal regeneration and functional outcome, and, for the first time, they definitively evaluated the degree of contribution of the native and donor motor neuron pools.

METHODS

This study was conducted in 2 phases. In phase I, rats (n = 35) were assigned to one of 5 groups for unilateral sciatic nerve surgeries: group 1, tibial NIC with distal peroneal-tibial SETS; group 2, tibial NIC without SETS; group 3, intact tibial and severed peroneal nerves; group 4, tibial transection with SETS; and group 5, severed tibial and peroneal nerves. Recovery was evaluated biweekly using electrophysiology and locomotion tasks. At the phase I end point, after retrograde labeling, the spinal cords were analyzed to assess the degree of neuronal regeneration. In phase II, 20 new animals underwent primary retrograde labeling of the tibial nerve, following which they were assigned to one of the following 3 groups: group 1, group 2, and group 4. Then, secondary retrograde labeling from the tibial nerve was performed at the study end point to quantify the native versus donor regenerated neuronal pool.

RESULTS

In phase I studies, a significantly increased neuronal regeneration in group 1 (SETS) compared with all other groups was observed, but with modest (nonsignificant) improvement in electrophysiological and behavioral outcomes. In phase II experiments, the authors discovered that secondary labeling in group 1 was predominantly contributed from the donor (peroneal) pool. Double-labeling counts were dramatically higher in group 2 than in group 1, suggestive of hampered regeneration from the native tibial motor neuron pool across the NIC segment in the presence of SETS.

CONCLUSIONS

SETS is indeed an effective strategy to enhance axonal regeneration, which is mainly contributed by the donor neuronal pool. Moreover, the presence of a distal SETS coaptation appears to negatively influence neuronal regeneration across the NIC segment. The clinical significance is that SETS should only employ synergistic donors, as the use of antagonistic donors can downgrade recovery.

Electrophysiologic recovery of the abductor pollicis brevis after contralateral C7 nerve transfer in 95 patients with global brachial plexus avulsion

In this study, we investigated the electrophysiologic recovery of the abductor pollicis brevis (APB) muscle after contralateral seventh cervical (cC7) nerve transfer for the treatment of global brachial plexus avulsion (GBPA). We retrospectively analyzed the electromyography records of 95 patients with GBPA, comprising 81 men and 14 women, focusing on the motor unit potential (MUP) recovery of the APB. All patients underwent cC7-median nerve (MN) transfer. The cC7 nerve was transferred to the MN alone in 58 patients (One-Nerve Group), whereas 37 patients underwent cC7 transfer to the MN and another nerve (Two-Nerve Group). Fifty-three patients (MUP Group) exhibited MUP recovery of the APB, whereas 42 patients did not (No-MUP Group). The MUP Group comprised 32 patients from the One-Nerve Group and 21 patients from the Two-Nerve Group. The mean age of the MUP Group was significantly lower than that of the No-MUP Group. In summary, electrophysiologic recovery of the APB was common in patients with GBPA after cC7-MN transfer, indicating that it may be possible to restore the function of the intrinsic muscles of the hand after GBPA. The rehabilitation strategy for patients with GBPA, which overlooks the restoration of intrinsic hand muscle function, may require amendment.

Systematic Review of Tendon Transfer Versus Nerve Transfer for the Restoration of Wrist Extension in Isolated Traumatic Radial Nerve Palsy

Purpose:

To compare the outcomes of tendon transfer and nerve transfer for radial nerve palsy.

Methods:

We performed a systematic review of the literature in EMBASE, PubMed, and Cochrane Database to include studies that address persistent traumatic radial nerve palsy treated with tendon transfer or nerve transfer surgery.

Results:

We identified 2,044 citations; 1,512 texts were excluded because of content, and 96 texts were screened for eligibility. Texts were excluded if they did not report the motor score (M0 to M5 as determined by the British Medical Research Council) or measurements of range of motion of the wrist. Sixteen texts were eligible for qualitative synthesis. Outcomes of these studies show heterogeneity with regard to the technique and functional restoration.

Conclusions:

On the basis of the results of this systematic review, there does not seem to be a clearly superior technique; rather, there are advantages and disadvantages to each. Patient selection and surgeon experience are important when considering surgical interventions in this challenging clinical scenario. Nerve transfer surgery is an emerging technique that may offer patients meaningful functional gains with reduced donor site morbidity.

Level of Evidence:

Level III

An All-Anterior Approach for Quadruple Nerve Transfer for Upper Trunk Brachial Plexus Injuries

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.

Transfer of the anterior branch of the obturator nerve for femoral nerve reconstruction and preservation of motor function: A case report

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Femoral nerve lesions are uncommon but severely disrupting at the functional level.

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Local nerve transfer can be a safe reconstructive option.

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Transfer of anterior branch of the obturator nerve is a low morbidity-procedure.

Introduction

Femoral nerve lesions are uncommon but severely disrupting at the functional level, because of the inability to walk, run, and passing from sitting to standing position. Reconstruction via local nerve transfer (neurotization) is a relatively new yet promising procedure.

Presentation of case

We describe a case of successful restoration of rectus femoris’ function after a malignant process by transfer of the anterior branch of the obturator nerve at the thigh level. At present, only few similar reports are present in the literature. Nerve gap after surgery was considerable (10 cm) and nerve grafting could have been unsatisfactory in terms of reinnervation. Therefore, reconstruction was managed with nerve isolation and transfer to the rectus femoris motor branch. The functional result was satisfactory at 1-year follow up with margins for further improvement.

Discussion

This case reported favorable outcomes of neurotization of the anterior branch of the obturator nerve for femoral nerve lesion. Reports of success with this procedure are still limited, but the promising results in terms of functional recovery suggest it should be offered to patients as a viable therapeutic option.

Conclusion

Advantages of neurotization compared to grafts are several, including: limiting suturing sites and scarring; shortening the recovery time by decreasing the required regeneration distance; and allowing for faster muscle reinnervation. The choice to transfer the anterior branch of the obturator nerve specifically allows to preserve part of the adductor functionality in the thigh without affecting the stability of the knee joint.

Salvage of cervical motor radiculopathy using peripheral nerve transfer reconstruction

Purpose: Motor nerve transfer surgery involves re-innervation of important distal muscles using either an expendable motor branch or a fascicle from an adjacent functioning nerve. This technique is established as part of the reconstructive algorithm for traumatic brachial plexus injuries. The reproducible outcomes of motor nerve transfer surgery have resulted in exploration of the application of this technique to other paralysing conditions. The objective of this study is to report feasibility and increase awareness about nerve transfer as a method of improving upper limb function in patients with cervical motor radiculopathy of different aetiology. Results: In this case series we report 3 cases with different modes of injury to the spinal nerve roots with significant and residual motor radiculopathy that have been successfully treated with nerve transfer surgery with good functional outcomes. The cases involved iatrogenic nerve root injury, tumour related root compression and degenerative root compression. Conclusion: Nerve transfer surgery may offer reliable reconstruction for paralysis when there has been no recovery following a period of conservative management. However the optimum timing of nerve transfer intervention is not yet identified for patients with motor radiculopathy.

Total brachial plexus injury: contralateral C7 root transfer to the lower trunk versus the median nerve

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.

Is it necessary to use the entire root as a donor when transferring contralateral C7 nerve to repair median nerve?

If a partial contralateral C₇ nerve is transferred to a recipient injured nerve, results are not satisfactory. However, if an entire contralateral C₇ nerve is used to repair two nerves, both recipient nerves show good recovery. These findings seem contradictory, as the above two methods use the same donor nerve, only the cutting method of the contralateral C₇ nerve is different. To verify whether this can actually result in different repair effects, we divided rats with right total brachial plexus injury into three groups. In the entire root group, the entire contralateral C₇ root was transected and transferred to the median nerve of the affected limb. In the posterior division group, only the posterior division of the contralateral C₇ root was transected and transferred to the median nerve. In the entire root + posterior division group, the entire contralateral C₇ root was transected but only the posterior division was transferred to the median nerve. After neurectomy, the median nerve was repaired on the affected side in the three groups. At 8, 12, and 16 weeks postoperatively, electrophysiological examination showed that maximum amplitude, latency, muscle tetanic contraction force, and muscle fiber cross-sectional area of the flexor digitorum superficialis muscle were significantly better in the entire root and entire root + posterior division groups than in the posterior division group. No significant difference was found between the entire root and entire root + posterior division groups. Counts of myelinated axons in the median nerve were greater in the entire root group than in the entire root + posterior division group, which were greater than the posterior division group. We conclude that for the same recipient nerve, harvesting of the entire contralateral C₇ root achieved significantly better recovery than partial harvesting, even if only part of the entire root was used for transfer. This result indicates that the entire root should be used as a donor when transferring contralateral C₇ nerve.

Evaluation of nerve transfer options for treating total brachial plexus avulsion injury: A retrospective study of 73 participants

Despite recent great progress in diagnosis and microsurgical repair, the prognosis in total brachial plexus-avulsion injury remains unfavorable. Insufficient number of donors and unreasonable use of donor nerves might be key factors. To identify an optimal treatment strategy for this condition, we conducted a retrospective review. Seventy-three patients with total brachial plexus avulsion injury were followed up for an average of 7.3 years. Our analysis demonstrated no significant difference in elbow-flexion recovery between phrenic nerve-transfer (25 cases), phrenic nerve-graft (19 cases), intercostal nerve (17 cases), or contralateral C₇-transfer (12 cases) groups. Restoration of shoulder function was attempted through anterior accessory nerve (27 cases), posterior accessory nerve (10 cases), intercostal nerve (5 cases), or accessory + intercostal nerve transfer (31 cases). Accessory nerve + intercostal nerve transfer was the most effective method. A significantly greater amount of elbow extension was observed in patients with intercostal nerve transfer (25 cases) than in those with contralateral C₇ transfer (10 cases). Recovery of median nerve function was noticeably better for those who received entire contralateral C₇ transfer (33 cases) than for those who received partial contralateral C₇ transfer (40 cases). Wrist and finger extension were reconstructed by intercostal nerve transfer (31 cases). Overall, the recommended surgical treatment for total brachial plexus-avulsion injury is phrenic nerve transfer for elbow flexion, accessory nerve + intercostal nerve transfer for shoulder function, intercostal nerves transfer for elbow extension, entire contralateral C₇ transfer for median nerve function, and intercostal nerve transfer for finger extension. The trial was registered at ClinicalTrials.gov (identifier: NCT03166033).

A neurophysiological approach to nerve transfer to restore upper limb function in cervical spinal cord injury

A successful nerve transfer surgery can provide a wealth of benefits to a patient with cervical spinal cord injury. The process of surgical decision making ideally uses all pertinent information to produce the best functional outcome. Reliance on clinical examination and imaging studies alone can miss valuable information on the state of spinal cord health. In this regard, neurophysiological evaluation has the potential to effectively gauge the neurological status of even select pools of anterior horn cells and their axons to small nerve branches in question to determine the potential efficacy of their use in a transfer. If available preoperatively, knowledge gained from such an evaluation could significantly alter the reconstructive surgical plan and avoid poor results. The authors describe their institution’s approach to the assessment of patients with cervical spinal cord injury who are being considered for nerve transfer surgery in both the acute and chronic setting and broadly review the neurophysiological techniques used.

Rapid and accurate peripheral nerve imaging by multipoint Raman spectroscopy

Raman spectroscopy allows label-free, minimally invasive, and accurate detection of peripheral nerves. However, the conventional Raman imaging technique is time-consuming when measuring a large area of a sample. Establishing a method for rapidly acquiring spatial distribution of a bundle of peripheral nerve fibers is an essential step for Raman spectroscopy towards application in clinical surgery. Here we present a multipoint Raman spectroscopic technique for rapid peripheral nerve imaging. In only 5 seconds, spectra at 32 points situated on ex vivo rat peripheral nerve bundles and adjoining connective tissues were acquired. Principal component regression and discriminant analysis of spectra revealed that the sensitivity, specificity and accuracy for nerve detection were 85.8%, 96.0%, and 90.8%, respectively. Of 158 peripheral nerves, 152 (96.2%) showed ratio of the number of nerve-positive prediction points to the total measurement points being 0.4 or larger, whereas 119 (99.2%) connective tissues among 120 showed ratio smaller than 0.4. Based on the ratio and a bright-field image of the sample, accurate visualization of peripheral nerves was implemented. The results indicated that the multipoint Raman spectroscopic technique is capable of rapid and accurate peripheral nerve imaging.

Nerve Transfer Versus Nerve Graft for Reconstruction of High Ulnar Nerve Injuries

PURPOSE

To assess the efficacy of nerve transfer versus nerve grafting in restoring motor and sensory hand function in patients with complete, isolated high ulnar nerve injuries.

METHODS

A retrospective chart review was performed, at a minimum 2 years of follow-up, of 52 patients suffering complete, isolated high ulnar nerve injury between January 2006 and June 2013 in one specialized hand surgery unit. Twenty-four patients underwent motor and sensory nerve transfers (NT group). Twenty-eight patients underwent sural nerve grafting (NG group). Motor recovery, return of sensibility and complications were examined as outcome measures. The Medical Research Council scale was applied to evaluate sensory and motor recovery. Grip and pinch strengths of the hand were measured.

RESULTS

Twenty of 24 patients (83.33%) in the NT group regained M3 grade or greater for the adductor pollicis, the abductor digiti minimi, and the medial 2 lumbricals and interossei, compared with only 16 of 28 patients (57.14%) in the NG group. Means for percentage recovery of grip strengths compared with the other healthy hand were significantly higher for the NT group than the NG group. Sensory recovery of S3 or greater was achieved in more than half of each group with no significant difference between groups.

CONCLUSIONS

Nerve transfer is favored over nerve grafting in managing high ulnar nerve injuries because of better improvement of motor power and better restoration of grip functions of the hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Long-Term Outcome of Brachial Plexus Reimplantation After Complete Brachial Plexus Avulsion Injury

Background

Complete brachial plexus avulsion injury is a severe disabling injury due to traction to the brachial plexus. Brachial plexus reimplantation is an emerging surgical technique for the management of complete brachial plexus avulsion injury.

Objective

We assessed the functional recovery in 15 patients who underwent brachial plexus reimplantation surgery after complete brachial plexus avulsion injury with clinical examination and electrophysiological testing.

Methods

We included all patients who underwent brachial plexus reimplantation in our institution between 1997 and 2010. Patients were assessed with detailed motor and sensory clinical examination and motor and sensory electrophysiological tests.

Results

We found that patients who had reimplantation surgery demonstrated an improvement in Medical Research Council power in the deltoid, pectoralis, and infraspinatous muscles and global Medical Research Council score. Eight patients achieved at least grade 3 MRC power in at least one muscle group of the arm. Improved reinnervation by electromyelography criteria was found in infraspinatous, biceps, and triceps muscles. There was evidence of ongoing innervation in 3 patients. Sensory testing in affected dermatomes also showed better recovery at C5, C6, and T1 dermatomes. The best recovery was seen in the C5 dermatome.

Conclusions

Our results demonstrate a definite but limited improvement in motor and sensory recovery after reimplantation surgery in patients with complete brachial plexus injury. We hypothesize that further improvement may be achieved by using regenerative cell technologies at the time of repair.

Radial nerve palsy

As a result of its proximity to the humeral shaft, as well as its long and tortuous course, the radial nerve is the most frequently injured major nerve in the upper limb, with its close proximity to the bone making it vulnerable when fractures occur.Injury is most frequently sustained during humeral fracture and gunshot injuries, but iatrogenic injuries are not unusual following surgical treatment of various other pathologies.Treatment is usually non-operative, but surgery is sometimes necessary, using a variety of often imaginative procedures. Because radial nerve injuries are the least debilitating of the upper limb nerve injuries, results are usually satisfactory.Conservative treatment certainly has a role, and one of the most important aspects of this treatment is to maintain a full passive range of motion in all the affected joints.Surgical treatment is indicated in cases when nerve transection is obvious, as in open injuries or when there is no clinical improvement after a period of conservative treatment. Different techniques are used including direct suture or nerve grafting, vascularised nerve grafts, direct nerve transfer, tendon transfer, functional muscle transfer or the promising, newer treatment of biological therapy. Cite this article: Bumbasirevic M, Palibrk T, Lesic A, Atkinson HDE. Radial nerve palsy. EFORT Open Rev 2016;1:286-294. DOI: 10.1302/2058-5241.1.000028.

Can an injured nerve be used as a donor nerve for distal nerve transfer?-An experimental study in rats

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.

The natural history and management of brachial plexus birth palsy

Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.

Severe Brachial Plexus Injuries in American Football

This article reports a series of severe permanent brachial plexus injuries in American football players. The authors describe the mechanisms of injury and outcomes from a more contemporary treatment approach in the form of nerve transfer tailored to the specific injuries sustained. Three cases of nerve transfer for brachial plexus injury in American football players are discussed in detail. Two of these patients regained functional use of the extremity, but 1 patient with a particularly severe injury did not regain significant function. Brachial plexus injuries are found along a spectrum of brachial plexus stretch or contusion that includes the injuries known as "stingers." Early identification of these severe brachial plexus injuries allows for optimal outcomes with timely treatment. Diagnosis of the place of a given injury along this spectrum is difficult and requires a combination of imaging studies, nerve conduction studies, and close monitoring of physical examination findings over time. Although certain patients may be at higher risk for stingers, there is no evidence to suggest that this correlates with a higher risk of severe brachial plexus injury. Unfortunately, no equipment or strengthening program has been shown to provide a protective effect against these severe injuries. Patients with more severe injuries likely have less likelihood of functional recovery. In these patients, nerve transfer for brachial plexus injury offers the best possibility of meaningful recovery without significant morbidity. [ Orthopedics. 2016; 39(6):e1188-e1192.].

Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review

BACKGROUND

The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure.

METHOD

A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design.

RESULTS

Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1 %) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21.

CONCLUSIONS

Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.

Reduced functional connectivity within the primary motor cortex of patients with brachial plexus injury

This study aims at the effects of traumatic brachial plexus lesion with root avulsions (BPA) upon the organization of the primary motor cortex (M1). Nine right-handed patients with a right BPA in whom an intercostal to musculocutaneous (ICN-MC) nerve transfer was performed had post-operative resting state fMRI scanning. The analysis of empirical functional correlations between neighboring voxels revealed faster correlation decay as a function of distance in the M1 region corresponding to the arm in BPA patients as compared to the control group. No differences between the two groups were found in the face area. We also investigated whether such larger decay in patients could be attributed to a gray matter diminution in M1. Structural imaging analysis showed no difference in gray matter density between groups. Our findings suggest that the faster decay in neighboring functional correlations without significant gray matter diminution in BPA patients could be related to a reduced activity in intrinsic horizontal connections in M1 responsible for upper limb motor synergies.

Results of spinal accessory to suprascapular nerve transfer in 110 patients with complete palsy of the brachial plexus

OBJECTIVE

Transfer of the spinal accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with total brachial plexus palsy. However, the results of this procedure remain largely unknown.

METHODS

Over an 11-year period (2002–2012), 257 patients with total brachial plexus palsy were operated upon in the authors' department by a single surgeon and had the spinal accessory nerve transferred to the suprascapular nerve. Among these, 110 had adequate follow-up and were included in this study. Their average age was 26 years (SD 8.4 years), and the mean interval between their injury and surgery was 5.2 months (SD 2.4 months). Prior to 2005, the suprascapular and spinal accessory nerves were dissected through a classic supraclavicular L-shape incision (n = 29). Afterward (n = 81), the spinal accessory and suprascapular nerves were dissected via an oblique incision, extending from the point at which the plexus crossed the clavicle to the anterior border of the trapezius muscle. In 17 of these patients, because of clavicle fractures or dislocation, scapular fractures or retroclavicular scarring, the incision was extended by detaching the trapezius from the clavicle to expose the suprascapular nerve at the suprascapular fossa. In all patients, the brachial plexus was explored and elbow flexion reconstructed by root grafting (n = 95), root grafting and phrenic nerve transfer (n = 6), phrenic nerve transfer (n = 1), or third, fourth, and fifth intercostal nerve transfer. Postoperatively, patients were followed for an average of 40 months (SD 13.7 months).

RESULTS

Failed recovery, meaning less than 30° abduction, was observed in 10 (9%) of the 110 patients. The failure rate was 25% between 2002 and 2004, but dropped to 5% after the staged/extended approach was introduced. The mean overall range of abduction recovery was 58.5° (SD 26°). Comparing before and after distal suprascapular nerve exploration (2005–2012), the range of abduction recovery was 45° (SD 25.1°) versus 62° (SD 25.3°), respectively (p = 0.002). In patients who recovered at least 30° of abduction, recovery of elbow flexion to at least an M3 level of strength increased the range of abduction by an average of 13° (p = 0.01). Before the extended approach, 2 (7%) of 29 patients recovered active external rotation of 20° and 120°. With the staged/extended approach, 32 (40%) of 81 recovered some degree of active external rotation. In these patients, the average range of motion measured from the thorax was 87° (SD 40.6°).

CONCLUSIONS

In total palsies of the brachial plexus, using the spinal accessory nerve for transfer to the suprascapular nerve is reliable and provides some recovery of abduction for a large majority of patients. In a few patients, a more extensive approach to access the suprascapular nerve, including, if necessary, dissection in the suprascapular fossa, may enhance outcomes.

Nerve Regeneration: Understanding Biology and Its Influence on Return of Function After Nerve Transfers

Poor functional outcomes are frequent after peripheral nerve injuries despite the regenerative support of Schwann cells. Motoneurons and, to a lesser extent, sensory neurons survive the injuries but outgrowth of axons across the injury site is slow. The neuronal regenerative capacity and the support of regenerating axons by the chronically denervated Schwann cells progressively declines with time and distance of the injury from the denervated targets. Strategies, including brief low-frequency electrical stimulation that accelerates target reinnervation and functional recovery, and the insertion of cross-bridges between a donor nerve and a recipient denervated nerve stump, are effective in promoting functional outcomes after complete and incomplete injuries.

Transdiscal C6-C7 contralateral C7 nerve root transfer in the surgical repair of brachial plexus avulsion injuries

BACKGROUND

Repair of complete brachial plexus avulsion injuries may require contralateral C7 nerve root transfer. The available techniques might allow direct neuroraphy in about 50 % of cases but the others require interposing nerve grafts or humeral shaft shortening. We aimed to see if transdiscal C6-C7 contralateral C7 nerve root transfer is technically feasible and if it allows direct coaptation with the contralateral nerve roots in 100 % of cases.

METHODS

In ten fresh-frozen adult cadavers, the C7 nerve root was sectioned just before it connects with other brachial plexus branches and re-routed though the C6-C7 disc space to the contralateral side. A complete C6-C7 discectomy was performed and the disc space kept open with the aid of an autologous iliac crest bone graft.

RESULTS

Transdiscal C6-C7 contralateral C7 nerve root transfer is technically feasible. In our cadavers, it provided 5.3 ± 1.2 SDcm of extra length that allowed direct coaptation with the contralateral nerve roots, mainly C8 and T1.

CONCLUSIONS

Transdiscal C6-C7 contralateral C7 nerve root transfer is technically feasible. In our dissections it lengthens the available C7 nerve root stump by 5.3 ± 1.2SDcm. The increase was 4 cm versus the retropharyngeal route making direct coaptation with the contralateral C8 and T1 nerve roots possible.

Motor Nerve Transfers

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.

Management of infraclavicular (Chuang Level IV) brachial plexus injuries: A single surgeon experience with 75 cases

Infraclavicular brachial plexus injuries (Level IV in Chuang's classification) have special characteristics, including high incidences of associated scapular fractures, glenohumeral dislocations, and vascular injuries. In addition, there are specific difficulties in surgical dissection and nerve repairs, especially if surgery is delayed (>3 months). A total of 153 patients with Level IV brachial plexus injuries underwent surgery between 1987 and 2008 with 75 patients (average age 29 years) available for a minimum of 4 years follow-up. Accompanying fractures/dislocations were suffered by 48 (64%) patients, and 17 (23%) had associated vascular injuries. The most common nerves to be injured were the axillary and musculocutaneous nerves. Nerve grafts to the axillary, musculocutaneous, and radial nerves achieved impressive results, but less reliable outcomes were achieved with the median and ulnar nerves. Decompression and/or external neurolysis were also beneficial for nerve recovery. Some surgical tips are presented, and the use of the C-loop vascularized ulnar nerve graft and functioning muscle transfers are discussed.

LEVEL OF EVIDENCE

IV.

Bionic reconstruction to restore hand function after brachial plexus injury: a case series of three patients

BACKGROUND

Brachial plexus injuries can permanently impair hand function, yet present surgical reconstruction provides only poor results. Here, we present for the first time bionic reconstruction; a combined technique of selective nerve and muscle transfers, elective amputation, and prosthetic rehabilitation to regain hand function.

METHODS

Between April 2011, and May 2014, three patients with global brachial plexus injury including lower root avulsions underwent bionic reconstruction. Treatment occurred in two stages; first, to identify and create useful electromyographic signals for prosthetic control, and second, to amputate the hand and replace it with a mechatronic prosthesis. Before amputation, the patients had a specifically tailored rehabilitation programme to enhance electromyographic signals and cognitive control of the prosthesis. Final prosthetic fitting was applied as early as 6 weeks after amputation.

FINDINGS

Bionic reconstruction successfully enabled prosthetic hand use in all three patients. After 3 months, mean Action Research Arm Test score increased from 5·3 (SD 4·73) to 30·7 (14·0). Mean Southampton Hand Assessment Procedure score improved from 9·3 (SD 1·5) to 65·3 (SD 19·4). Mean Disabilities of Arm, Shoulder and Hand score improved from 46·5 (SD 18·7) to 11·7 (SD 8·42).

INTERPRETATION

For patients with global brachial plexus injury with lower root avulsions, who have no alternative treatment, bionic reconstruction offers a means to restore hand function.

FUNDING

Austrian Council for Research and Technology Development, Austrian Federal Ministry of Science, Research & Economy, and European Research Council Advanced Grant DEMOVE.

Transfer of the brachialis to the anterior interosseous nerve as a treatment strategy for cervical spinal cord injury: technical note

Study Design Technical report. Objective To provide a technical description of the transfer of the brachialis to the anterior interosseous nerve (AIN) for the treatment of tetraplegia after a cervical spinal cord injury (SCI). Methods In this technical report, the authors present a case illustration of an ideal surgical candidate for a brachialis-to-AIN transfer: a 21-year-old patient with a complete C7 spinal cord injury and failure of any hand motor recovery. The authors provide detailed description including images and video showing how to perform the brachialis-to-AIN transfer. Results The brachialis nerve and AIN fascicles can be successfully isolated using visual inspection and motor mapping. Then, careful dissection and microsurgical coaptation can be used for a successful anterior interosseous reinnervation. Conclusion The nerve transfer techniques for reinnervation have been described predominantly for the treatment of brachial plexus injuries. The majority of the nerve transfer techniques have focused on the upper brachial plexus or distal nerves of the lower brachial plexus. More recently, nerve transfers have reemerged as a potential reinnervation strategy for select patients with cervical SCI. The brachialis-to-AIN transfer technique offers a potential means for restoration of intrinsic hand function in patients with SCI.

Nerve transfer helps repair brachial plexus injury by increasing cerebral cortical plasticity

In the treatment of brachial plexus injury, nerves that are functionally less important are transferred onto the distal ends of damaged crucial nerves to help recover neuromuscular function in the target region. For example, intercostal nerves are transferred onto axillary nerves, and accessory nerves are transferred onto suprascapular nerves, the phrenic nerve is transferred onto the musculocutaneous nerves, and the contralateral C₇ nerve is transferred onto the median or radial nerves. Nerve transfer has become a major method for reconstructing the brachial plexus after avulsion injury. Many experiments have shown that nerve transfers for treatment of brachial plexus injury can help reconstruct cerebral cortical function and increase cortical plasticity. In this review article, we summarize the recent progress in the use of diverse nerve transfer methods for the repair of brachial plexus injury, and we discuss the impact of nerve transfer on cerebral cortical plasticity after brachial plexus injury.