Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series

Socolovsky, Mariano; Cardoso, Marcio de Mendonça; Lovaglio, Ana; Masi, Gilda Di; Bonilla, Gonzalo; Gepp, Ricardo de Amoreira

doi:10.1093/ons/opaa163

Cited by 4 publications

(7 citation statements)

References 35 publications

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“…We found a similar study published recently which concluded that supraclavicular PN transfer had better results compared to VATS aided PN transfer for restoration of elbow flexion in brachial plexus injuries. 19 However, this study was a comparison made between two medical centers and it was not mentioned if the surgeons’ level of expertise were comparable. There were too many variables for target nerve coaptation in supraclavicular PN transfer group and some were sutured directly without nerve graft.…”

Section: Discussionmentioning

confidence: 99%

Video-assisted thoracoscopic surgery (VATS) aided full-length phrenic nerve transfer for restoration of elbow flexion

Gunasagaran

Wahab

Khoo

et al. 2023

J Orthop Surg (Hong Kong)

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Background In complete brachial plexus injury, phrenic nerve (PN) is frequently used in neurotization for elbow flexion restoration. The advancement in video-assisted thoracoscopic surgery (VATS) allows full-length PN dissection intrathoracically for direct coaptation to recipient without nerve graft. Purpose We report our experience in improving the surgical technique and its outcome. Methods Seven patients underwent PN dissection via VATS and full-length transfer to musculocutaneous nerve (MCN) or motor branch of biceps (MBB) from June 2015 to June 2018. Comparisons were made with similar group of patients who underwent conventional PN transfer. Results Mean age of patients was 21.9 years. All were males involved in motorcycle accidents who sustained complete brachial plexus injury. We found the elbow flexion recovery were earlier in full-length PN transfer. However, there was no statistically significant difference in elbow flexion strength at 3 years post-surgery. Conclusion We propose full-length PN transfer for restoration of elbow flexion in patients with delayed presentation.

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Section: Discussionmentioning

confidence: 99%

Video-assisted thoracoscopic surgery (VATS) aided full-length phrenic nerve transfer for restoration of elbow flexion

Gunasagaran

Wahab

Khoo

et al. 2023

J Orthop Surg (Hong Kong)

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“…If the anterior division of the upper trunk is unaffected, a direct nerve transfer of the phrenic nerve via supraclavicular approach to the anterior division of the upper trunk could be performed. However, this procedure may be associated with axonal misrouting caused by choosing a too proximal target [ 15 ]. Thus, a direct phrenic nerve transfer to the musculocutaneous nerve is certainly preferable.…”

Section: Discussionmentioning

confidence: 99%

“…The qualitative systematic review by Cardoso et al [ 9 ] showed that elbow flexor muscle strength had been graded ≥ M3 (movement against gravity is just possible) according to the British Medical Research Council scale [ 10 , 11 ] in 70.1% of patients following phrenic nerve transfer to the musculocutaneous nerve. Phrenic nerve transfer to the musculocutaneous nerve can be achieved by means of video-assisted thoracic surgery without nerve graft [ 3 , 5 , 9 , 12 , 13 , 14 , 15 ] or via supraclavicular approach in combination with an autograft [ 12 , 15 , 16 ]. It could be shown in a recent study that patients who underwent supraclavicular sectioning of the nerve in combination with an autograft had a significantly better clinical outcome (elbow flexion strength recovery) compared to patients treated by video-assisted thoracoscopic technique without nerve autograft [ 15 ].…”

Section: Introductionmentioning

confidence: 99%

“…Phrenic nerve transfer to the musculocutaneous nerve can be achieved by means of video-assisted thoracic surgery without nerve graft [ 3 , 5 , 9 , 12 , 13 , 14 , 15 ] or via supraclavicular approach in combination with an autograft [ 12 , 15 , 16 ]. It could be shown in a recent study that patients who underwent supraclavicular sectioning of the nerve in combination with an autograft had a significantly better clinical outcome (elbow flexion strength recovery) compared to patients treated by video-assisted thoracoscopic technique without nerve autograft [ 15 ]. Furthermore, Socolovsky et al showed that the functional clinical outcome was better in patients with a shorter nerve graft than in patients with a longer nerve graft (9.8 vs. 15.1 cm) [ 9 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

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Phrenic Nerve Transfer to Musculocutaneous Nerve: An Anatomical and Histological Study

Fochtmann-Frana,

Pretterklieber,

Radtke

et al. 2023

Life

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Background: To restore elbow flexor muscle function in case of traumatic brachial plexus avulsion, the phrenic nerve transfer to the musculocutaneous nerve has become part of clinical practice. The nerve transfer can be done by means of video-assisted thoracic surgery without nerve graft or via supraclavicular approach in combination with an autograft. This study focuses on a detailed microscopic and macroscopic examination of the phrenic nerve. It will allow a better interpretation of existing clinical results and, thus, serve as a basis for future clinical studies. Material and Methods: An anatomical study was conducted on 28 body donors of Caucasian origin (female n = 14, male n = 14). A sliding caliper and measuring tape were used to measure the diameter and length of the nerves. Sudan black staining was performed on 15 µm thick cryostat sections mounted on glass slides and the number of axons was determined by the ImageJ counting tool. In 23 individuals, the phrenic nerve could be examined on both sides. In 5 individuals, however, only one side was examined. Thus, a total of 51 nerves were examined. Results: The mean length of the left phrenic nerves (33 cm (29–38 cm)) was significantly longer compared to the mean length of the right phrenic nerves (30 cm (24–33 cm)) (p < 0.001). Accessory phrenic nerves were present in 9 of 51 (18%) phrenic nerves. The mean number of phrenic nerves axons at the level of the first intercostal space in body donors with a right accessory phrenic nerve was significantly greater compared to the mean number of phrenic nerves axons at the same level in body donors without a right accessory phrenic nerve (3145 (range, 2688–3877) vs. 2278 (range, 1558–3276)), p = 0.034. A negative correlation was registered between age and the nerve number of axons in left (0.742, p < 0.001) and right (−0.273, p = 0.197) phrenic nerves. The mean distance from the upper edge of the ventral ramus of the fourth cervical spinal nerve to the point of entrance of the musculocutaneous nerve between the two parts of the coracobrachialis muscle was 19 cm (range, 15–24 cm) for the right and 20 cm (range, 15–25 cm) for the left arm. Conclusions: If an accessory phrenic nerve is available, it presumably should be spared. Thus, in that case, a supraclavicular approach in combination with a nerve graft would probably be of advantage.

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“…2 The ICN-MCN transfer was the preferred choice for elbow flexion reconstruction in total or C5-8 types of BPI because of limitations in alternative NTs such as phrenic NTs with postoperative pulmonary complications and inconsistent recovery results after contralateral C7 root transfer. 3 , 4 , 5 , 6 …”

mentioning

confidence: 99%

Virtual Rehabilitation of Elbow Flexion Following Nerve Transfer Reconstruction for Brachial Plexus Injuries Using the Single-Joint Hybrid Assisted Limb

Doi¹,

Chia²,

Hattori³

et al. 2022

Journal of Hand Surgery Global Online

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The upper limb single-joint hybrid assistive limb (HAL), a wearable robot that can support elbow flexion and extension motions, was originally used to rehabilitate patients with stroke. We report the preliminary outcomes of serial HAL use for rehabilitation following nerve transfer (NT) for elbow flexion reconstruction in brachial plexus injuries. Methods: Hybrid assistive limb training consisted of virtual and power training courses. Virtual training was started before HAL picked up motor unit potentials (MUPs) from the target muscle through electrodes attached to the skin overlying the original donor muscles. Power training was started after the maturation of MUPs, the stage where the MUPs were strong to be recognized to arise from the target muscles. Hybrid assistive limb assist at this stage was carried out by decreasing the settings in an inversely proportionate manner to the increase in target muscle strength. Fourteen patients underwent HAL training following NT. Eight patients had the intercostal nerve to musculocutaneous nerve (ICN-MCN) transfer, and their postoperative functional outcomes and rehabilitation performance were compared to 50 patients with ICN-MCN transfer who underwent conventional postoperative rehabilitation with electromyographic biofeedback (EMG-BF) techniques. Results: Comparison of the long-term results following ICN-MCN transfer between EMG-BF and HAL groups showed similar follow-up times, elbow flexion range of motion, or power of elbow flexion assessed using the British Medical Council grade, and quantitative measurement using Kin-Com dynamometer. However, the number of rehabilitation sessions was significantly fewer in the HAL than EMG-BF group. Conclusion: HAL training accelerated patients' learning to convert the original muscle function into elbow flexion following NT by replicating elbow flexion during the pre-MUP detection stage and shortening the rehabilitation time.Type of study/level of evidence: Therapeutic IV.

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Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series

Cited by 4 publications

References 35 publications

Video-assisted thoracoscopic surgery (VATS) aided full-length phrenic nerve transfer for restoration of elbow flexion

Video-assisted thoracoscopic surgery (VATS) aided full-length phrenic nerve transfer for restoration of elbow flexion

Phrenic Nerve Transfer to Musculocutaneous Nerve: An Anatomical and Histological Study

Virtual Rehabilitation of Elbow Flexion Following Nerve Transfer Reconstruction for Brachial Plexus Injuries Using the Single-Joint Hybrid Assisted Limb

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