An anatomic study of the spinal accessory nerve: Extended harvest permits direct nerve transfer to distal plexus targets

Vathana, Torpon; Larsen, Mikko; Ruiter, Godard C.W. de; Bishop, Allen T.; Spinner, Robert J.; Shin, Alexander Y.

doi:10.1002/ca.20545

Cited by 42 publications

(25 citation statements)

References 23 publications

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“…[2][3][4][5][6][7][8][9][10][11][12] Different approaches have been used to evaluate the outcomes of nerve regeneration. [13][14][15][16][17] Obtaining a measurement of the maximum output force of the muscle is of much relevance to clinical recovery after nerve repair, 18,19 and side-to-side comparison is a practical method to evaluate recovery avoiding inter-specimen differences. In a previous study in normal untreated Lewis rats, we validated the isometric muscle force test using the tibialis anterior (TA) muscle and demonstrated a side-to-side variability of 4% when preload and electrical parameters were optimized.…”

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confidence: 99%

Description and validation of isometric tetanic muscle force test in rabbits

et al. 2011

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Isometric tetanic muscle force has been described in a rat model to evaluate motor recovery in a segmental sciatic nerve defect reconstructions. However, to test longer nerve defects, an alternative and larger animal model is necessary. The purpose of this study is to describe and validate a technique for isometric force measurement of the tibialis anterior (TA) muscle in New Zealand rabbits. Muscle preload and electrical stimulation parameters were optimized to obtain the highest tetanic contraction bilaterally in 10 animals. Electrophysiology, muscle weight, peroneal nerve length, and histomorphometry were also analyzed. Only the peroneal nerve length and the ratio of highest muscle force/muscle weight demonstrated the equivalence between the sides. A small variability of TA muscle force and TA muscle weight was observed between the sides suggesting dominance. Optimization of electrical stimulation and preload as well as the use of correct anesthesia were fundamental to acquire the highest muscle force.

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confidence: 99%

Description and validation of isometric tetanic muscle force test in rabbits

et al. 2011

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“…However, external rotation recovery remains poor in agreement with previous reports. 10,12 We propose 2 possible explanations for the absence of external rotation recovery observed in our patients with complete palsy: 1) The number of myelinated fibers in the accessory nerve is insufficient to match that in the suprascapular nerve (1300 vs 3800, respectively); 10,19 being the first to be reinnervated, the supraspinatus muscle attracts more regenerating axons that the infraspinatus.…”

Section: Discussionmentioning

confidence: 87%

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

Bertelli

Ghizoni

2016

SPI

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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.

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“…Preservation of the more proximal branches of the accessory nerve may be another advantage of the posterior approach. The anatomic studies have demonstrated that the number of nerve axons decreases from the proximal to terminal portion of the SAN 20. The motor axons at a very distal level may be inadequate to reinnervate the recipient SSN 20, 21.…”

Section: Discussionmentioning

confidence: 99%

“…The anatomic studies have demonstrated that the number of nerve axons decreases from the proximal to terminal portion of the SAN 20. The motor axons at a very distal level may be inadequate to reinnervate the recipient SSN 20, 21. It would be better to harvest the SSN more proximally to ensure adequate motor axons from the SAN but a enough length for direct nerve neurorrhaphy in the nerve transfer.…”

Section: Discussionmentioning

confidence: 99%

Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach

et al. 2011

Microsurgery

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The upper brachial plexus injury leads to paralysis of muscles innervated by C5 and C6 nerve roots. In this report, we present our experience on the use of the combined nerve transfers for reconstruction of the upper brachial plexus injury. Nine male patients with the upper brachial plexus injury were treated with combined nerve transfers. The time interval between injury and surgery ranged from 3 to 11 months (average, 7 months). The combined nerve transfers include fascicles of the ulnar nerve and/or the median nerve transfer to the biceps and/or the brachialis motor branch, and the spinal accessory nerve (SAN) to the suprascapular nerve (SSN) and triceps branches to the axillary nerve through a posterior approach. At an average of 33 months of follow-up, all patients recovered the full range of the elbow flexion. Six out of nine patients were able to perform the normal range of shoulder abduction with the strength degraded to M3 or M4. These results showed that the technique of the combined nerve transfers, specifically the SAN to the SSN and triceps branches to the axillary nerve through a posterior approach, may be a valuable alternative in the repair of the upper brachial plexus injury. Further evaluations of this technique are necessary.

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An anatomic study of the spinal accessory nerve: Extended harvest permits direct nerve transfer to distal plexus targets

Cited by 42 publications

References 23 publications

Description and validation of isometric tetanic muscle force test in rabbits

Description and validation of isometric tetanic muscle force test in rabbits

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

Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach

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