Evaluation of suprascapular nerve neurotization after nerve graft or transfer in the treatment of brachial plexus traction lesions

Injury and Biological Factors Impact Shoulder Function following Autogenous Grafting of Spinal Nerves for Pan-Brachial Plexus Reconstruction

BACKGROUND

Shoulder function after spinal nerve grafting in pan-brachial plexus injuries (pan-BPI) is not well described. The authors evaluated shoulder abduction (ABD) and external rotation (ER) after spinal nerve grafting to the suprascapular nerve, axillary nerve, or posterior division of the upper trunk and determined patient characteristics, injury severity and characteristics, and nerve graft factors that influenced outcomes.

METHODS

A total of 362 patients undergoing pan-BPI reconstruction and spinal nerve grafting for shoulder reanimation in a single institution between 2001 and 2018 were reviewed. Patient demographics, Injury Severity Score (ISS), graft characteristics, strength, range of motion for shoulder ABD and ER, and patient-reported outcomes were recorded. Patients were divided into 3 groups based on recovery of shoulder function: no return, ABD only, and ABD and ER.

RESULTS

A total of 110 patients underwent spinal nerve grafting, with 41 meeting inclusion criteria. Seventeen (41.5%) had no return of shoulder function, 14 (34.1%) had ABD alone, and 10 (24.4%) had ABD and ER. Patients with recovery of both ABD and ER were significantly younger (18.6 ± 5.56 years), had lower body mass index (22.4 ± 4.0), and had a lower ISS (10.5 ± 6.24; P = 0.003). Multivariable analysis found that with increasing age (OR, 0.786; 95% CI, 0.576, 0.941) and ISS (OR, 0.820; 95% CI, 0.606, 0.979), odds for return of ABD and ER decreased significantly.

CONCLUSIONS

In pan-BPI, 24.4% of patients demonstrated return of both ABD and ER after spinal nerve grafting to suprascapular nerve and either axillary nerve or posterior division of the upper trunk. Age, body mass index, and ISS were associated with poorer recovery of shoulder function. Careful patient selection and consideration of age, body mass index, and ISS may improve outcomes of spinal nerve grafting for shoulder reanimation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The association between number of intercostal nerves transferred and elbow flexion: a systematic review and pooled analysis

OBJECTIVE

This pooled analysis evaluates the association between the number of nerves transferred and postoperative outcomes after intercostal nerve (ICN) nerve transfer for elbow flexion.

METHODS

A systematic and pooled analysis of studies reporting individual patient demographics and outcomes after ICN-musculocutaneous nerve (MCN) transfer for traumatic brachial plexus injury was conducted. The primary outcome was the ability to attain an elbow flexion Medical Research Council (MRC) score of ≥4 at the final postoperative follow-up visit.

RESULTS

Ten studies were included for a total of 128 patients. There were 43 patients who underwent two ICNT, 77 patients who underwent three ICNT, and 8 patients who underwent four ICNT. The three groups did not differ in ability to achieve MRC ≥ 4 (2ICNT 48.8%, 3ICNT 42.9%, 4ICNT 50.0%, p = 0.789). The number of ICNs transferred was not associated with MRC scores ≥4 on the multivariable analysis (OR: 0.55, p = 0.126).

CONCLUSIONS

These results indicate that two ICN transfers may be as effective as three ICN and four ICN transfers and highlight the potential for nonsurgical factors to influence postoperative outcomes. Taken together, this pooled analysis leads us to question the utility of transferring >2 ICNs for MCN neurotization.

Direct Hemi-Hypoglossal Nerve and Hypoglossal Nerve for Suprascapular Nerve/Proximal Brachial Plexus Neurotization: A Cadaveric Feasibility Study

Introduction Partial restoration of shoulder function is important in upper brachial plexus lesions, and the suprascapular nerve is often the target for such neurotization procedures. Although there is an extensive history of peripheral nerve surgeons using the hypoglossal nerve for various local nerve transfers, some have reported using this nerve as a donor for upper brachial plexus grafting procedures. We discuss our anatomical findings for the use of a direct hypoglossal to suprascapular nerve transfer. Materials and methods Fifteen adult cadavers (30 separate sides) were dissected to reveal the hypoglossal nerve in the neck and the supraclavicular brachial plexus in the supraclavicular region. On 15 sides, the hypoglossal nerve was dissected anteriorly to the midline, cut, and transposed toward the supraclavicular region in half of the dissections. On the remaining sides, the nerve was hemisected longitudinally into two equal parts, and the cut inferior portion also swung inferiorly toward the supraclavicular region. The cut end of the hypoglossal nerve was brought toward the proximal suprascapular nerve, the fifth (C5) and sixth (C6) cervical nerve roots, and the upper trunk. Measurements included the length and diameter of the cervical portion of the hypoglossal nerve and the diameter of the suprascapular nerve. Results The mean diameter and length of the hypoglossal nerve were 2.1 millimeters (mm) and 72.8 mm, respectively. The mean diameter of the proximal suprascapular nerve was 2.7 mm. Successful, tension-free transposition to the C5 and C6 nerve roots was achieved on all sides. The average extra length of the hypoglossal nerve for a C5 root transposition was 8 mm and 5.2mm for a C6 root transposition. The distal hypoglossal nerve reached the upper trunk on all but two sides (6.7%). The distal hypoglossal nerve reached the proximal suprascapular nerve on all but four sides (13.3%). Of the 87% of sides (n=26) where the hypoglossal nerve reached the proximal suprascapular nerve, 58% of these (n=15) required some manipulation of the suprascapular nerve from its origin at the upper trunk. This technique resulted in a mean additional length to the suprascapular nerve of 35 mm. No differences were found between the completely cut hypoglossal nerves and hemisected nerves in regard to working length. Conclusions To our knowledge, the use of the hypoglossal nerve as a transpositional graft for direct suprascapular nerve neurotization has not been previously described. Based on our study, we propose that the hypoglossal nerve, or hemi-hypoglossal nerve, should be considered as a donor nerve to restore suprascapular nerve function in the majority of patients. Additionally, the hypoglossal nerve may be transferred to the C5 and C6 roots and upper trunk of the brachial plexus for direct neurotization.

Shoulder Arthrodesis for Traumatic Brachial Plexus Injuries: Functional Outcomes and Complications

BACKGROUND

The external rotation and abduction of shoulder are considered one of the priorities of reconstruction in brachial plexus injury. The aim of this study was to evaluate the functional results and complications of shoulder arthrodesis in patients with brachial plexus injury to better comprehend the benefits of this procedure.

METHODS

Between 2015 and 2019, 15 shoulder arthrodesis were performed in patients with long-standing brachial plexus injury. The main indication for arthrodesis was absent or poor recovery of shoulder abduction and external rotation. Patients presented different levels of injury. Shoulder measurements of active abduction and external rotation were made based on image records of the patients. A long 4.5-mm reconstruction plate was fit along the scapular spine, acromion, and lateral proximal third of the humerus. Structured bone graft was fit into the subacromial space.

RESULTS

The mean preoperative abduction was 16°, and the mean postoperative abduction was 42°. The mean preoperative external rotation was -59°, and the mean postoperative external rotation was -13°. The mean increase in abduction and external rotation was 25° and 45°, respectively. Bone union was achieved in all cases at an average time of 5.23 months. We experienced humeral fractures in 26.66% of the cases, which were all successfully treated nonoperatively.

CONCLUSIONS

Shoulder arthrodesis is a rewarding procedure for patients with brachial plexus injuries. A marked improvement in the upper limb positioning was observed in all patients. It should be considered as the main therapeutic option in cases where nerve reconstruction is no longer possible.

Diagnostic accuracy of magnetic resonance imaging for nerve injury in obstetric brachial plexus injury: protocol for systematic review and meta-analysis

BACKGROUND

Early and accurate clinical diagnosis of the extent of obstetric brachial plexus injury (OBPI) is challenging. The current gold standard for delineating the nerve injury is surgical exploration, and synchronous reconstruction is performed if indicated. Magnetic resonance imaging (MRI) is a non-invasive method of assessing the anatomy and severity of nerve injury in OBPI but the diagnostic accuracy is unclear. The primary objective of this review is to determine the diagnostic accuracy of MRI in comparison to surgical brachial plexus exploration for detecting root avulsion in children under 5 with OBPI. The secondary objectives are to determine its' diagnostic accuracy for detecting nerve abnormality and detecting pseudomeningocele(s) in this group.

METHODS

This review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).We will include studies reporting the accuracy of MRI (index test) compared to surgical exploration (reference standard) in detecting any of the three target conditions (root avulsion, any nerve abnormality and pseudomeningocele) in children under five with OBPI. Case reports and studies where the number of true positives, false positives, true negatives and false negatives cannot be derived will be excluded. We plan to search PubMed, Embase and CENTRAL for relevant studies from database inception to 15 June 2022. We will also search grey literature (medRxiv, bioRxiv and Google Scholar) and perform forward and backward citation chasing. Screening and full-text assessment of eligibility will be conducted by two independent reviewers, who will then both extract the relevant data. The QUADAS-2 tool will be used to assess methodological quality and risk of bias of included studies by two reviewers independently. The following test characteristics for the target conditions will be extracted: true positives, false positives, true negatives and false negatives. Estimates of sensitivity and specificity with 95% confidence intervals will be shown in forest plots for each study. If appropriate, summary sensitivities and specificities for target conditions will be obtained via meta-analyses using a bivariate model.

DISCUSSION

This study will aim to clarify the diagnostic accuracy of MRI for detecting nerve injury in OBPI and define its clinical role.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021267629.

The Demography of Traumatic Brachial Plexus Avulsion Injuries

Background and objective

Brachial plexus injuries more commonly affect the younger generation who constitute the productive workforce. The patients who sustain avulsion injuries of the brachial plexus are more often involved in high-velocity accidents. The avulsion injuries are surgically managed by nerve transfers. This study aimed to evaluate the demography of brachial plexus avulsion injuries.

Materials and methods

This retrospective study was conducted in January 2013 and included 21 patients treated from January 2007 to December 2011.

Results

Of the 21 patients, 20 were male and the most commonly affected patients were in the age group of 21-30 years. The mean age of the affected patients was 27.24 years. Six of the patients had pan palsy (C5-8 and T1), nine had C5-7 injury, and six had C5-6 injury. Twenty patients underwent spinal accessory to suprascapular nerve transfer, nine patients underwent ulnar nerve fascicle to nerve to biceps branch transfer, and one patient underwent intercostal nerve to musculocutaneous nerve transfer. Of note, 40% of the patients regained more than M3 power for abduction and external rotation of the shoulder, and 30% of the patients regained more than M3 power for elbow function.

Conclusions

Road traffic accidents are the most common cause of brachial plexus injuries. Nerve transfers for shoulder and elbow function play a significant role in improving the function of the upper extremity.

Transferência nervosa da raiz de C4 para C5 em lesões do plexo braquial. Estudo anatômico e descrição de técnica cirúrgica

Objective  This is an anatomical study of C4 and C5 roots for nerve transfers in upper brachial plexus injuries, with surgical technique demonstration.

Methods  Fifteen brachial plexuses from both male and female cadavers were dissected. Morphological features of C4 and C5 roots were recorded and analyzed, followed by a neurotization simulation.

Results  In all dissections, C4 and C5 roots morphological features allowed their mobilization and neurotization with no need for a nerve graft. The surgical technique spared important regional nerve branches.

Conclusion  Based on these data, we conclude that C4-C5 nerve transfers are feasible and result in no additional neurological deficit in upper brachial plexus injuries.

Outcomes of Spinal Accessory Nerve and Intercostal Nerve Transfers for Shoulder Stabilisation and Elbow Extension in Patients with C5,6,7 Root Avulsion Injury

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)

Micropatterned Poly(D,L-Lactide-Co-Caprolactone) Conduits With KHI-Peptide and NGF Promote Peripheral Nerve Repair After Severe Traction Injury

Severe traction injuries after stretch to peripheral nerves are common and challenging to repair. The nerve guidance conduits (NGCs) are promising in the regeneration and functional recovery after nerve injuries. To enhance the repair of severe nerve traction injuries, in this study KHIFSDDSSE (KHI) peptides were grafted on a porous and micropatterned poly(D,L-lactide-co-caprolactone) (PLCL) film (MPLCL), which was further loaded with a nerve growth factor (NGF). The adhesion number of Schwann cells (SCs), ratio of length/width (L/W), and percentage of elongated SCs were significantly higher in the MPLCL-peptide group and MPLCL-peptide-NGF group compared with those in the PLCL group in vitro. The electromyography (EMG) and morphological changes of the nerve after severe traction injury were improved significantly in the MPLCL-peptide group and MPLCL-peptide-NGF group compared with those in the PLCL group in vivo. Hence, the NGCs featured with both bioactive factors (KHI peptides and NGF) and physical topography (parallelly linear micropatterns) have synergistic effect on nerve reinnervation after severe traction injuries.

The nerve to the levator scapulae muscle as donor in brachial plexus surgery: an anatomical study and case series

OBJECTIVE

Nerve transfers are commonly used in treating complete injuries of the brachial plexus, but donor nerves are limited and preferentially directed toward the recovery of elbow flexion and shoulder abduction. The aims of this study were to characterize the anatomical parameters for identifying the nerve to the levator scapulae muscle (LSN) in brachial plexus surgery, to evaluate the feasibility of transferring this branch to the suprascapular nerve (SSN) or lateral pectoral nerve (LPN), and to present the results from a surgical series.

METHODS

Supra- and infraclavicular exposure of the brachial plexus was performed on 20 fresh human cadavers in order to measure different anatomical parameters for identification of the LSN. Next, an anatomical and histomorphometric evaluation of the feasibility of transferring this branch to the SSN and LPN was made. Lastly, the effectiveness of the LSN-LPN transfer was evaluated among 10 patients by quantifying their arm adduction strength.

RESULTS

The LSN was identified in 95% of the cadaveric specimens. A direct coaptation of the LSN and SSN was possible in 45% of the specimens (n = 9) but not between the LSN and LPN in any of the specimens. Comparison of axonal counts among the three nerves did not show any significant difference. Good results from reinnervation of the major pectoral muscle (Medical Research Council grade ≥ 3) were observed in 70% (n = 7) of the patients who had undergone LSN to LPN transfer.

CONCLUSIONS

The LSN is consistently identified through a supraclavicular approach to the brachial plexus, and its transfer to supply the functions of the SSN and LPN is anatomically viable. Good results from an LSN-LPN transfer are observed in most patients, even if long nerve grafts need to be used.

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

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.

What Range of Motion is Achieved 5 Years After External Rotationplasty of the Shoulder in Infants with an Obstetric Brachial Plexus Injury?

BACKGROUND

Obstetric brachial plexus injuries result from traction injuries during delivery, and 30% of these children have persisting functional limitations related to an external rotation deficit of the shoulder. Little is known about the long-term effect of soft-tissue procedures of the shoulder in patients with obstetric brachial plexus injuries.

QUESTIONS/PURPOSES

(1) After soft-tissue release for patients with passive external rotation less than 20° and age younger than 2 years and for patients older than 2 years with good external rotation strength, what are the improvements in passive external rotation and abduction arcs at 1 and 5 years? (2) For patients who underwent staged tendon transfer after soft-tissue release, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? (3) For patients with passive external rotation less than 20° and no active external rotation, what are the improvements in active external rotation and abduction arcs at 1 and 5 years?

METHODS

This was a retrospective analysis of a longitudinally maintained institutional database. Between 1996 and 2009, 149 children underwent a soft-tissue procedure of the shoulder for an internal rotation contracture. The inclusion criteria were treatment with an internal contracture release and/or tendon transfer, a maximum age of 18 years at the time of surgery, and a minimum follow-up period of 2 years. Six patients were older than 18 years at the time of surgery and 31 children were seen at our clinic until 1 year postoperatively, but because they had good clinical results and lived far away from our center, these children were discharged to physical therapists in their hometown for annual follow-up. Thus, 112 children (59 boys) were available for analysis. Patients with passive external rotation less than 20° and age younger than 2 years and patients older than 2 years with good external rotation strength received soft-tissue release only (n = 37). Of these patients, 17 children did not have adequate active external rotation, and second-stage tendon transfer surgery was performed. For patients with passive external rotation less than 20° with no active external rotation, single-stage contracture release with tendon transfer was performed (n = 68). When no contracture was present (greater than 20° of external rotation) but the patient had an active deficit (n = 7), tendon transfer alone was performed; this group was not analyzed. A functional assessment of the shoulder was performed preoperatively and postoperatively at 6 weeks, 3 months, and annually thereafter and included abduction, external rotation in adduction and abduction, and the Mallet scale.

RESULTS

Internal contracture release resulted in an improvement in passive external rotation in adduction and abduction of 29° (95% confidence interval, 21 to 38; p < 0.001) and 17° (95% CI, 10 to 24; p < 0.001) at 1 year of follow-up and 25° (95% CI, 15-35; p < 0.001) and 15° (95% CI, 7 to 24; p = 0.001) at 5 years. Because of insufficient strength of the external rotators after release, 46% of the children (17 of 37) underwent an additional tendon transfer for active external rotation, resulting in an improvement in active external rotation in adduction and abduction at each successive follow-up visit. Patients with staged transfers had improved active function; improvements in active external rotation in adduction and abduction were 49° (95% CI, 28 to 69; p < 0.05) and 45° (95% CI, 11 to 79; p < 0.001) at 1 year of follow-up and 38° (95% CI, 19 to 58; p < 0.05) and 23° (95% CI, -8 to 55; p < 0.001) at 5 years. In patients starting with less than 20° of passive external rotation and no active external rotation, after single-stage contracture release and tendon transfer, active ROM was improved. Active external rotation in adduction and abduction were 75° (95% CI, 66 to 84; p < 0.001) and 50° (95% CI, 43 to 57; p < 0.001) at 1 year of follow-up and 65° (95% CI, 50 to 79; p < 0.001) and 40° (95% CI, 28 to 52; p < 0.001) at 5 years.

CONCLUSION

Young children with obstetric brachial plexus injuries who have internal rotation contractures may benefit from soft-tissue release. When active external rotation is lacking, soft-tissue release combined with tendon transfer improved active external rotation in this small series. Future studies on the degree of glenohumeral deformities and functional outcome might give more insight into the level of increase in external rotation.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Nerve Transfers-A Paradigm Shift in the Reconstructive Ladder

In this review, we present the current role of nerve transfers in the management of nerve injuries. The outcome of a literature review comparing the results of nerve graft versus nerve transfer and the experience of select surgical societies' members regarding experience and adoption of nerve transfer are reported. Nerve transfer publications have increased more than nerve graft or repair articles. The surgeon survey revealed an increase in nerve transfers and that more motor nerve transfers have been adopted into practice compared to sensory nerve transfers. The meta-analyses and systematic reviews of motor nerve transfers for shoulder and elbow function presented variable outcomes related to donor nerve selection. Comprehensive patient assessment is essential to evaluate the immediate functional needs and consider future reconstruction that may be necessary. Optimal outcome following nerve injury may involve a combination of different surgical options and more than one type of reconstruction. Nerve transfer is a logical extension of the paradigm shift from nerve repair and nerve graft and offers a new rung on the reconstruction ladder.

A New Surgical Technique for Internal Shoulder Contractures Secondary to Obstetric Brachial Plexus Injury: An Anterior Coracohumeral Ligament Release

Background  Obstetric brachial plexus injuries result from traction injury during delivery; 30% of these children sustain persisting functional limitations related to an external rotation deficit of the shoulder. The aim of this study was to compare the intraoperative gain in external rotation after a posterior subscapular release and an anterior coracohumeral ligament release.

Methods  This is a prospective study on 102 children with an internal rotation contracture of the shoulder who received either a posterior subscapular release (posterior skin incision along the medial border of the scapula of 3–5 cm) or an anterior (5-mm skin incision) coracohumeral ligament release between 1996 and 2010. After general anesthesia, internal and external rotations in both adduction and abduction were measured before and after the surgical release.

Results  After a posterior subscapular release, the intraoperative external rotation improved with a mean of 64 degrees (95% confidence interval [CI]: 54–74; p  < 0.001) in adduction and with a mean of 41 degrees (95% CI: 32–49; p  < 0.001) in abduction. After an anterior coracohumeral ligament release, external rotation increased with a mean of 61 degrees (95% CI: 56–66; p  < 0.001) in adduction and a mean of 42 degrees in abduction (95%CI: 39–45, p  < 0.001). Differences between these two groups were not statistically different.

Conclusion  The anterior release technique shows comparable results with the posterior subscapular release. And since it is performed through a smaller incision of 5 mm, this is our preferred method to increase passive external rotation.

Level of evidence  II.

Nerve Transfers-A Paradigm Shift in the Reconstructive Ladder

Supplemental Digital Content is available in the text.

In this review, we present the current role of nerve transfers in the management of nerve injuries. The outcome of a literature review comparing the results of nerve graft versus nerve transfer and the experience of select surgical societies’ members regarding experience and adoption of nerve transfer are reported. Nerve transfer publications have increased more than nerve graft or repair articles. The surgeon survey revealed an increase in nerve transfers and that more motor nerve transfers have been adopted into practice compared to sensory nerve transfers. The meta-analyses and systematic reviews of motor nerve transfers for shoulder and elbow function presented variable outcomes related to donor nerve selection. Comprehensive patient assessment is essential to evaluate the immediate functional needs and consider future reconstruction that may be necessary. Optimal outcome following nerve injury may involve a combination of different surgical options and more than one type of reconstruction. Nerve transfer is a logical extension of the paradigm shift from nerve repair and nerve graft and offers a new rung on the reconstruction ladder.

Lower Trapezius Transfer for Patients With Brachial Plexus Injury

BACKGROUND

Brachial plexus injury is a complex entity that often results in partial recovery. Most studies to date have focused on improving shoulder abduction. However, a recent technique has been outlined-one that transfers the lower trapezius to improve the external rotation of the shoulder. The primary objective of this study was to evaluate the gains in external rotation of the shoulder in patients who have undergone transfer of the lower trapezius; secondarily, we assessed the range of motion in the elbow and shoulder joints, as well as the muscle strength and quality of life.

METHODS

This article presents a prospective cohort study of 10 patients who underwent transfer of the lower trapezius. During the preoperative period and at 6 months after the operation, both active and passive goniometric measurements were assessed, as were muscle strength, Mallet's classification, and patients' responses to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire.

RESULTS

External rotation exhibited an improvement of 17° in the active range of motion and 14° the passive range, which was not statistically significant. Flexion and active abduction of the shoulder, as well as the responses to the DASH, showed positive results. The Mallet's classification and muscle strength measurement results were not significant.

CONCLUSIONS

The procedure might be an alternative for restoration of shoulder function and glenohumeral stabilization and mainly to improve quality of life. However, additional studies are required to define and refine this surgical technique.

Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study

INTRODUCTION

Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury.

METHODS

PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed.

RESULTS

In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022).

CONCLUSIONS

Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery.

LEVEL OF EVIDENCE

Level II.

Early nerve repair in traumatic brachial plexus injuries in adults: treatment algorithm and first experiences

OBJECTIVE

The object of this study was to assess the advantages and disadvantages of early nerve repair within 2 weeks following adult traumatic brachial plexus injury (ATBPI).

METHODS

From 2009 onwards, the authors have strived to repair as early as possible extended C-5 to C-8 or T-1 lesions or complete loss of C-5 to C-6 or C-7 function in patients in whom there was clinical and radiological suspicion of root avulsion. Among a group of 36 patients surgically treated in the period between 2009 and 2011, surgical findings in those who had undergone treatment within 2 weeks after trauma were retrospectively compared with results in those who had undergone delayed treatment. The result of biceps muscle reanimation was the primary outcome measure.

RESULTS

Five of the 36 patients were referred within 2 weeks after trauma and were eligible for early surgery. Nerve ruptures and/or avulsions were found in all early cases of surgery. The advantages of early surgery are as follows: no scar formation, easy anatomical identification, and gap length reduction. Disadvantages include less-clear demarcation of vital nerve tissue and unfamiliarity with the interpretation of frozen-section examination findings. All 5 early-treatment patients recovered a biceps force rated Medical Research Council grade 4.

CONCLUSIONS

Preliminary results of nerve repair within 2 weeks of ATBPI are encouraging, and the benefits outweigh the drawbacks. The authors propose a decision algorithm to select patients eligible for early surgery. Referral standards for patients with ATBPI must be adapted to enable early surgery.

ASSESSMENT OF THE RESULTS OF ACCESSORY TO SUPRASCAPULAR NERVE TRANSFER

Objective

Nerve transfers are an alternative in the reconstruction of traumatic brachial plexus injuries. In this study, we report the results of branchial plexus reconstruction using accessory to suprascapular nerve transfer.

Methods

Thirty-three patients with traumatic brachial plexus injuries underwent surgical reconstruction with accessory to suprascapular nerve transfers. The patients were divided into groups in which surgery was performed either within 6 months after the injury or more than 6 months after the injury. Results were assessed using the Constant score.

Results

There was no significant difference between the groups with respect to the Constant score.

Conclusion

Accessory to suprascapular nerve transfer was not an efficient method for recovering active ROM or strength in the shoulder. However, it effectively improved pain control and shoulder stability. Level of evidence II, Retrospective Study.

Recovery of Elbow Flexion after Nerve Reconstruction versus Free Functional Muscle Transfer for Late, Traumatic Brachial Plexus Palsy: A Systematic Review

BACKGROUND

In late presentation of brachial plexus trauma, it is unclear whether donor nerves should be devoted to nerve reconstruction or reserved for free functional muscle transfer. The authors systematically reviewed recovery of elbow flexion after nerve reconstruction versus free functional muscle transfer for late, traumatic brachial plexus palsy.

METHODS

A systematic review was performed using the PubMed, Embase, and Cochrane databases to identify all cases of traumatic brachial plexus palsy in patients aged 18 years or older. Patients who underwent late (≥12 months) nerve reconstruction or free functional muscle transfer for elbow flexion were included. Age, time to operation, and level of brachial plexus injury were recorded. British Medical Research Council grade for strength and range of motion were evaluated for elbow flexion.

RESULTS

Thirty-three studies met criteria, for a total of 103 patients (nerve reconstruction, n = 53; free functional muscle transfer, n = 50). There were no differences across groups regarding surgical age (time from injury) and preoperative elbow flexion. For upper trunk injuries, 53 percent of reconstruction patients versus 100 percent of muscle transfer patients achieved grade M3 or greater strength, and 43 percent of reconstruction patients versus 70 percent of muscle transfer patients achieved grade M4 or greater strength. Of the total brachial plexus injuries, 37 percent of reconstruction patients versus 78 percent of muscle transfer patients achieved grade M3 or greater strength, and 16 percent of reconstruction patients versus 46 percent of muscle transfer patients achieved grades M4 or greater strength.

CONCLUSION

In late presentation of traumatic brachial plexus injuries, donor nerves should be reserved for free functional muscle transfer to restore elbow flexion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Landmarks for Identifying the Suprascapular Foramen Anteriorly: Application to Anterior Neurotization and Decompressive Procedures

BACKGROUND

Additional landmarks for identifying the suprascapular nerve at its entrance into the suprascapular foramen from an anterior approach would be useful to the surgeon.

OBJECTIVE

To identify landmarks for the identification of this hidden site within an anterior approach.

METHODS

In 8 adult cadavers (16 sides), lines were used to connect the superior angle of the scapula, the acromion, and the coracoid process tip thus creating an anatomic triangle. The suprascapular nerve's entrance into the suprascapular foramen was documented regarding its position within this anatomical triangle. Depths from the skin surface and specifically from the medial-most point of the clavicular attachment of the trapezius to the suprascapular nerve's entrance into the suprascapular foramen were measured using calipers and a ruler. The clavicle was then fractured and retracted superiorly to verify the position of the nerve's entrance into the suprascapular foramen.

RESULTS

From the trapezius, the nerve's entrance into the foramen was 3 to 4.2 cm deep (mean, 3.5 cm). The mean distance from the tip of the corocoid process to the suprascapular foramen was 3.8 cm. The angle best used to approach the suprascapular foramen from the surface was 15° to 20°.

CONCLUSION

Based on our study, an anterior suprascapular approach to the suprascapular nerve as it enters the suprascapular foramen can identify the most medial fibers of the trapezius attachment onto the clavicle and insert a finger at an angle of 15° to 20° laterally and advanced to an average depth of 3.5 cm.

Axillary nerve neurotization by a triceps motor branch: comparison between axillary and posterior arm approaches

Objectives

This study is aimed at comparing the functional outcome of axillary nerve neurotization by a triceps motor branch through the axillary approach and posterior arm approach.

Methods

The study included 27 patients with post-traumatic brachial plexus injury treated with axillary nerve neurotization by a triceps motor branch for functional recovery of shoulder abduction and external rotation. The patients were retrospectively evaluated and two groups were identified, one with 13 patients undergoing axillary nerve neurotization by an axillary approach and the second with 14 patients using the posterior arm approach. Patients underwent assessment of muscle strength using the scale recommended by the British Medical Research Council, preoperatively and 18 months postoperatively, with useful function recovery considered as grade M3 or greater.

Results

In the axillary approach group, 76.9% of patients achieved useful abduction function recovery and 69.2% achieved useful external rotation function recovery. In the group with posterior arm approach, 71.4% of patients achieved useful abduction function recovery and 50% achieved useful external rotation function recovery. The difference between the two groups was not statistically significant (p = 1.000 for the British Medical Research Council abduction scale and p = 0.440 for external rotation).

Conclusion

According to the British Medical Research Council grading, axillary nerve neurotization with a triceps motor branch using axillary approach or posterior arm approach shows no statistical differences.

Analysis of shoulder abduction by dynamic shoulder radiograph following suprascapular nerve repair in brachial plexus injury

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.

Injuries to the upper extremities in polytrauma: limited effect on outcome more than ten years after injury - a cohort study in 629 patients

AIMS

To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients.

PATIENTS AND METHODS

A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients' injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion.

RESULTS

In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC.

CONCLUSION

Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255-60.

Rhomboid nerve transfer to the suprascapular nerve for shoulder reanimation in brachial plexus palsy: A clinical report

Recovery of shoulder function is a real challenge in cases of partial brachial plexus palsy. Currently, in C5-C6 root injuries, transfer of the long head of the triceps brachii branch is done to revive the deltoid muscle. Spinal accessory nerve transfer is typically used for reanimation of the suprascapular nerve. We propose an alternative technique in which the nerve of the rhomboid muscles is transferred to the suprascapular nerve. A 33-year-old male patient with a C5-C6 brachial plexus injury with shoulder and elbow flexion palsy underwent surgery 7 months after the injury. The rhomboid nerve was transferred to the suprascapular nerve and the long head of the triceps brachii branch to the axillary nerve for shoulder reanimation. A double transfer of fascicles was performed, from the ulnar and median nerves to the biceps brachii branch and brachialis branch, respectively, for elbow flexion. At 14 months' follow-up, elbow flexion was rated M4. Shoulder elevation was 85 degrees and rated M4, and external rotation was 80 degrees and rated M4. After performing a cadaver study showing that transfer of the rhomboid nerve to the suprascapular nerve is technically possible, here we report and discuss the clinical outcomes of this new transfer technique.

Quantitative Dixon MRI sequences to relate muscle atrophy and fatty degeneration with range of motion and muscle force in brachial plexus injury

BACKGROUND

Assessment of muscle atrophy and fatty degeneration in brachial plexus injury (BPI) could yield valuable insight into pathophysiology and could be used to predict clinical outcome. The objective of this study was to quantify and relate fat percentage and cross-sectional area (CSA) of the biceps to range of motion and muscle force of traumatic brachial plexus injury (BPI) patients.

METHODS

T1-weighted TSE sequence and three-point Dixon images of the affected and non-affected biceps brachii were acquired on a 3 Tesla magnetic resonance scanner to determine the fat percentage, total and contractile CSA of 20 adult BPI patients. Regions of interest were drawn by two independent investigators to determine the inter-observer reliability. Paired Students' t-test and multivariate analysis were used to relate fat percentage, total and contractile CSA to active flexion and biceps muscle force.

RESULTS

The mean fat percentage 12±5.1% of affected biceps was higher than 6±1.0% of the non-affected biceps (p<0.001). The mean contractile CSA 8.1±5.1cm² of the affected biceps was lower than 19.4±4.9cm² of the non-affected biceps (p<0.001). The inter-observer reliability was excellent (ICC 0.82 to 0.96). The contractile CSA contributed most to the reduction in active flexion and muscle force.

CONCLUSION

Quantitative measurement of fat percentage, total and contractile CSA using three-point Dixon sequences provides an excellent reliability and relates with active flexion and muscle force in BPI.

Long-term clinical outcomes of spinal accessory nerve transfer to the suprascapular nerve in patients with brachial plexus palsy

BACKGROUND

For the reconstruction of brachial plexus lesions, restoration of elbow flexion and shoulder function is fundamental and is achieved by dual nerve transfers. Shoulder stabilization and movement are crucial in freedom of motion of the upper extremity. In patients with C5-C6 brachial plexus injury, spinal accessory nerve transfer to the suprascapular nerve and a fascicle of ulnar nerve to musculocutaneous nerve (dual nerve transfer) are carried out for restoration of shoulder abduction and elbow flexion, respectively. In the present study, we evaluated the long-term clinical outcomes of spinal accessory nerve transfer to the suprascapular nerve for restoration of shoulder abduction in patients with brachial plexus palsy undergoing a dual nerve transfer.

PATIENTS AND METHODS

In the present retrospective review, 22 consecutive subjects with upper brachial plexus palsy were assessed. All of the subjects underwent spinal accessory nerve transfer to the suprascapular nerve and a dual nerve transfer from the ulnar nerve to the biceps branch and from the median nerve to the brachialis branch of the musculocutaneous nerve simultaneously. All of the subjects were followed up for 18 to 24 months (average, 21.7 months) for assessing the recovery of the shoulder abduction and motor function.

RESULTS

Spinal accessory nerve transfer to the suprascapular nerve showed a motor function recovery of M3 and M4 in 13.6 and 63.6% of the subjects, respectively. However, 22.7 % of the subjects remained with a motor function of M2. The mean of shoulder abduction reached 55.55 ± 9.95° (range, 40-72°). Altogether, good functional results regained in 17 out of 22 the subjects (77.2 %). Linear regression analysis showed that advanced age was a predictor of low motor functional grade.

CONCLUSIONS

The evidence from the present study suggests that transferring spinal accessory nerve to the suprascapular nerve for restoring shoulder abduction is an effective and reliable treatment with high success rate in patients with brachial plexus palsy, especially in young patients.

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.

Evaluation of infraspinatus reinnervation and function following spinal accessory nerve to suprascapular nerve transfer in adult traumatic brachial plexus injuries

PURPOSE

Our objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results.

METHODS

Fifty-one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow-up. The primary outcome measured was shoulder ER. The outcomes we utilized included "clinically useful ER" (motion ≥ -35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation.

RESULTS

EMG evidence of re-innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow-up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: -60° to 90°) and MRC grade 2.2 (2-4). The only predictor of ER improvement was an isolated upper trunk (C5-C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5-C6-C7 and panplexus injuries, respectively (P < 0.03).

CONCLUSIONS

Although 85% had EMG signs of recovery, the SAN to SSN transfer failed to provide useful recovery of ER through reinnervation of the infraspinatus muscle in injuries involving more levels than a C5-C6 root/upper trunk pattern. In patients with greater than C5-6 level injuries alternatives to SAN to SSN transfer should be considered to restore shoulder ER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:365-370, 2017.

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.

Nerve Transfers to Restore Shoulder Function

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.

Nerve transfers and neurotization in peripheral nerve injury, from surgery to rehabilitation

Peripheral nerve injury (PNI) and recent advances in nerve reconstruction (such as neurotization with nerve transfers) have improved outcomes for patients suffering peripheral nerve trauma. The purpose of this paper is to bridge the gap between the electromyographer/clinical neurophysiologist and the peripheral nerve surgeon. Whereas the preceding literature focuses on either the basic science behind nerve injury and reconstruction, or the surgical options and algorithms, this paper demonstrates how electromyography is not just a 'decision tool' when deciding whether to operate but is also essential to all phases of PNI management including surgery and rehabilitation. The recent advances in the reconstruction and rehabilitation of PNI is demonstrated using case examples to assist the electromyographer to understand modern surgical techniques and the unique demands they ask from electrodiagnostic testing.

Clinical and neurobiological advances in promoting regeneration of the ventral root avulsion lesion

Root avulsions due to traction to the brachial plexus causes complete and permanent loss of function. Until fairly recent, such lesions were considered impossible to repair. Here we review clinical repair strategies and current progress in experimental ventral root avulsion lesions. The current gold standard in patients with a root avulsion is nerve transfer, whereas reimplantation of the avulsed root into the spinal cord has been performed in a limited number of cases. These neurosurgical repair strategies have significant benefit for the patient but functional recovery remains incomplete. Developing new ways to improve the functional outcome of neurosurgical repair is therefore essential. In the laboratory, the molecular and cellular changes following ventral root avulsion and the efficacy of intervention strategies have been studied at the level of spinal motoneurons, the ventral spinal root and peripheral nerve, and the skeletal muscle. We present an overview of cell-based pharmacological and neurotrophic factor treatment approaches that have been applied in combination with surgical reimplantation. These interventions all demonstrate neuroprotective effects on avulsed motoneurons, often accompanied with various degrees of axonal regeneration. However, effects on survival are usually transient and robust axon regeneration over long distances has as yet not been achieved. Key future areas of research include finding ways to further extend the post-lesion survival period of motoneurons, the identification of neuron-intrinsic factors which can promote persistent and long-distance axon regeneration, and finally prolonging the pro-regenerative state of Schwann cells in the distal nerve.

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.

Lesiones altas del plexo braquial. Reconstrucción con técnicas combinadas de neurotización e injertos nerviosos

<p>Las lesiones altas del plexo braquial  son  reconstruidas  con neurotización e  injerto nervioso. El  nervio espinal accesorio,  la raíz   C7,  ramas del tríceps, y  el nervio mediano y cubital son los más  usados para transferencias.</p><p>Se muestra la experiencia con  neurotización de la rama inferior del nervio espinal accesorio (NEA) al nervio supraescapular (NSE), transferencia nerviosa de fascículos del nervio cubital o del mediano, y en ocasiones  injertos nervioso hacia el nervio musculocutáneo  y al tronco posterior, y reconstrucción del nervio axilar  en algunos casos.</p><p><strong>Materiales y métodos</strong></p><p>Se revisan 42  pacientes  con  lesiones altas de plexo braquial, operados  mediante combinación de   neurotización  e injertos nerviosos. Seguimiento mínimo de 15 meses.</p><p><strong>Resultados  </strong></p><p>40 pacientes fueron por accidente en moto. En 22 se  transfirió únicamente el NSE con el NEA, recuperando  abducción de hombro  de 33º  En 8  pacientes  que se combinó con reparación del axilar, mejoró la abducción a 81º.</p><p>En 30 pacientes con neurotización del nervio cubital o mediano para el bíceps, se obtuvo respuesta  entre 3 y 4 meses. Al  final  flexión  del codo de 116º y M4.</p><p><strong>Discusión</strong></p><p>Los mejores resultados  en  hombro  fueron con la combinación  de NSE y del nervio axilar, logrando 81º de abducción. La rotación externa  mejoro  en 28.5% de los pacientes, siendo una respuesta tardía</p><p>La neurotización  del bíceps con fascículos del cubital consiguió una flexión    de 116º, muy  comparable con otras series. Hoy  esta técnica es el  <em>gold estándar</em>   para la reconstrucción de  flexión del codo. </p>

Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques

OBJECT

Adult upper trunk brachial plexus injuries result in significant disability. Several surgical treatment strategies exist, including nerve grafting, nerve transfers, and a combination of both approaches. However, no existing data clearly indicate the most successful strategy for restoring elbow flexion and shoulder abduction in these patients. The authors reviewed the literature to compare outcomes of the three surgical repair techniques listed above to determine the optimal approach to traumatic injury to the upper brachial plexus in adults.

METHODS

Both PubMed and EMBASE databases were searched for English-language articles containing the MeSH topic "brachial plexus" in conjunction with the word "injury" or "trauma" in the title and "surgery" or "repair" as a MeSH subheading or in the title, excluding pediatric articles and those articles limited to avulsions. The search was also limited to articles published after 1990 and containing at least 10 operated cases involving upper brachial plexus injuries. The search was supplemented with articles obtained through the "Related Articles" feature on PubMed and the bibliographies of selected publications. From the articles was collected information on the operation performed, number of operated cases, mean subject ages, sex distribution, interval between injury and surgery, source of nerve transfers, mean duration of follow-up, year of publication, and percentage of operative success in terms of elbow flexion and shoulder abduction of the injured limb. The recovery of elbow flexion and shoulder abduction was separately analyzed. A subanalysis was also performed to assess the recovery of elbow flexion following various neurotization techniques.

RESULTS

As regards the restoration of elbow flexion, nerve grafting led to significantly better outcomes than either nerve transfer or the combined techniques (F = 4.71, p = 0.0097). However, separating the Oberlin procedure from other neurotization techniques revealed that the former was significantly more successful (F = 82.82, p < 0.001). Moreover, in comparing the Oberlin procedure to nerve grafting or combined procedures, again the former was significantly more successful than either of the latter two approaches (F = 53.14; p < 0.001). In the restoration of shoulder abduction, nerve transfer was significantly more successful than the combined procedure (p = 0.046), which in turn was significantly better than nerve grafting procedures (F = 5.53, p = 0.0044).

CONCLUSIONS

According to data in this study, in upper trunk brachial plexus injuries in adults, the Oberlin procedure and nerve transfers are the more successful approaches to restore elbow flexion and shoulder abduction, respectively, compared with nerve grafting or combined techniques. A prospective, randomized controlled trial would be necessary to fully elucidate differences in outcome among the various surgical approaches.

Advances in nerve transfer surgery

Peripheral nerve injuries are devastating injuries and can result in physical impairments, poor functional outcomes and high levels of disability. Advances in our understanding of peripheral nerve regeneration and nerve topography have lead to the development of nerve transfers to restore function. Over the past two decades, nerve transfers have been performed and modified. With the advancements in surgical management and recognition of importance of cortical plasticity, motor-reeducation and perioperative rehabilitation, nerve transfers are producing improved functional outcomes in patients with nerve injuries. This manuscript explores the recent literature as it relates to current nerve transfer techniques and advances in post-operative rehabilitation protocols, with a focus on indications, techniques and outcomes.

Recent advances in the management of brachial plexus injuries

Management of brachial plexus injury is a demanding field of hand and upper extremity surgery. With currently available microsurgical techniques, functional gains are rewarding in upper plexus injuries. However, treatment options in the management of flail and anaesthetic limb are still evolving. Last three decades have witnessed significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in the diagnostic modalities, incorporation of intra-operative nerve stimulation techniques, more liberal use of nerve grafts in bridging nerve gaps, and the addition of new nerve transfers, which selectively neurotise the target muscles close to the motor end plates. Newer research works on the use of nerve allografts and immune modulators (FK 506) are under evaluation in further improving the results in nerve reconstruction. Direct reimplantation of avulsed spinal nerve roots into the spinal cord is another area of research in brachial plexus reconstruction.

Prevalence of rotator cuff tears in adults with traumatic brachial plexus injuries

BACKGROUND

Restoration of shoulder function is a primary goal when treating patients with traumatic brachial plexus injury. A concomitant rotator cuff tear may alter the treatment approach and prognosis for these individuals. The purpose of this study was to define the prevalence of rotator cuff tears in patients with traumatic brachial plexus injuries.

METHODS

This is a retrospective review of 280 adult patients with traumatic brachial plexus injury treated at a single institution over a twelve-year period. An upper-extremity magnetic resonance imaging (MRI) scan was acquired for all patients as part of the initial evaluation for posttraumatic brachial plexus injury. The radiographic and clinical data on these patients were reviewed to document partial or full-thickness rotator cuff tears, mechanism and location of the brachial plexus injury, and age.

RESULTS

Twenty-three patients (8.2%) had a full-thickness rotator cuff tear: one patient had tears involving three tendons, eight patients had tears involving two tendons, twelve patients had a single-tendon tear, one patient had a single-tendon tear in each shoulder, and one patient had a single-tendon tear in one shoulder and a two-tendon tear in the other. Twenty-one tears involved the supraspinatus, eight involved the infraspinatus, and seven involved the subscapularis. Thirteen patients underwent surgical repair of the rotator cuff. The average age of the patients in this cohort was 33.4 years, and older age was associated with an increased risk of full-thickness rotator cuff tears (odds ratio [OR], 1.06 per year). Patients with infraclavicular brachial plexus injury had a significantly higher rate of full-thickness rotator cuff tears.

CONCLUSIONS

Concomitant rotator cuff tears are present in approximately one in ten patients with traumatic brachial plexus injury. These injuries may contribute to shoulder dysfunction; therefore, evaluation of the rotator cuff with imaging studies is appropriate when formulating treatment strategies.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Local injection of autologous bone marrow cells to regenerate muscle in patients with traumatic brachial plexus injury: a pilot study

Objectives

Traumatic brachial plexus injury causes severe functional impairment of the arm. Elbow flexion is often affected. Nerve surgery or tendon transfers provide the only means to obtain improved elbow flexion. Unfortunately, the functionality of the arm often remains insufficient. Stem cell therapy could potentially improve muscle strength and avoid muscle-tendon transfer. This pilot study assesses the safety and regenerative potential of autologous bone marrow-derived mononuclear cell injection in partially denervated biceps.

Methods

Nine brachial plexus patients with insufficient elbow flexion (i.e., partial denervation) received intramuscular escalating doses of autologous bone marrow-derived mononuclear cells, combined with tendon transfers. Effect parameters included biceps biopsies, motor unit analysis on needle electromyography and computerised muscle tomography, before and after cell therapy.

Results

No adverse effects in vital signs, bone marrow aspiration sites, injection sites, or surgical wound were seen. After cell therapy there was a 52% decrease in muscle fibrosis (p = 0.01), an 80% increase in myofibre diameter (p = 0.007), a 50% increase in satellite cells (p = 0.045) and an 83% increase in capillary-to-myofibre ratio (p < 0.001) was shown. CT analysis demonstrated a 48% decrease in mean muscle density (p = 0.009). Motor unit analysis showed a mean increase of 36% in motor unit amplitude (p = 0.045), 22% increase in duration (p = 0.005) and 29% increase in number of phases (p = 0.002).

Conclusions

Mononuclear cell injection in partly denervated muscle of brachial plexus patients is safe. The results suggest enhanced muscle reinnervation and regeneration.

Cite this article: Bone Joint Res 2014;3:38–47.

Spinal to accessory nerve transfer in traumatic brachial plexus palsy: is body mass index a predictor of outcome?

INTRODUCTION

Several factors that affect functional recovery after surgery in severe brachial plexus lesions have been identified, i.e., time to surgery and presence of root avulsions. The body mass index (BMI) of the patient could be one of these possible factors. The objective of the present paper is to systematically study the relationship between BMI and the outcome of abduction following spinal accessory to suprascapular nerve transfer.

METHODS

We retrospectively studied 18 cases that followed these inclusion criteria: (1) Male patients with a spinal accessory to suprascapular nerve transfer as the only procedure for shoulder function reanimation; (2) at least C5-C6 root avulsion; (3) interval between trauma and surgery less than 12 months; (4) follow-up was at least 2 years; (5) no concomitant injury of the shoulder girdle. Pearson correlation analysis and linear regression was performed for BMI versus shoulder abduction.

RESULTS

The mean range of post-operative abduction obtained across the entire series was 49.7° (SD ± 30.2). Statistical evaluation revealed a significant, negative moderately strong correlation between BMI and post-operative range of shoulder abduction (r = -0.48, p = 0.04). Upon simple linear regression, time to surgery (p = 0.04) was the only statistically significant predictor of abduction range negatively correlated.

CONCLUSIONS

Analysis of this series suggests that a high BMI of patients undergoing brachial plexus surgery is a negative predictor of outcome, albeit less important than others like time from trauma to surgery. Nevertheless, the BMI of patients should be taken into consideration when planning surgical strategies for reconstruction.

Brachial plexus reconstruction following resection of a malignant peripheral nerve sheath tumor: case report

BACKGROUND AND IMPORTANCE

The main therapeutic approach for malignant peripheral nerve sheath tumors (MPNSTs) of the brachial plexus is wide local excision. Sacrifice of some--occasionally all--elements of the brachial plexus often is required to obtain complete resection, and therefore can be associated with significant morbidity. While peripheral nerve repair is commonly used in the setting of traumatic nerve injury, little is known about its potential use in the treatment of MPNST.

CLINICAL PRESENTATION

We present a patient with an enlarging right neck mass who was diagnosed with MPNST of the brachial plexus. The patient underwent gross total resection of the tumor, requiring sectioning of the upper trunk of the brachial plexus, as well as associated divisions. Following resection, sural nerve grafts were used to connect the C5 nerve root to the anterior division of the upper trunk and the spinal accessory nerve to the suprascapular nerve, whereas a triceps branch of the radial nerve was coapted directly to the anterior division of the axillary nerve.

CONCLUSION

By 20 months after surgery, the patient had regained significant strength in her upper trunk distribution and demonstrated no evidence of tumor recurrence. Brachial plexus reconstruction offers a potentially valuable surgical adjunct to MPNST treatment.