Motor Recovery and The Breathing Arm After Brachial Plexus Surgical Repairs, Including Re-Implantation of Avulsed Spinal Roots Into The Spinal Cord

Abstract

Forty-four patients with severe traction brachial plexus avulsion injuries were studied following surgical repairs. In eight patients, re-implanting avulsed spinal roots directly to the spinal cord was performed with other repairs and motor recovery in the proximal limb was similar to that achieved by conventional nerve grafts and transfers when assessed using the MRC clinical grades, Narakas scores, EMG and Transcranial Magnetic Stimulation (TMS). Thirty-four of the 37 patients had co-contractions of agonist and antagonist muscle groups. Spontaneous contractions of limb muscles in synchrony with respiration, the "breathing arm", were noted in 26 of 37 patients: in three patients, the source of the breathing arm was from spinal cord re-connection, providing evidence of regeneration from the CNS to the periphery. Our study shows that re-connection of avulsed spinal roots can produce good motor recovery and provides a clinical model for developing new treatments which may enhance nerve regeneration.

Results of Grafting the Anterior and Posterior Divisions of the Upper Trunk in Complete Palsies of the Brachial Plexus

“…36 In the study of Narakas and Herzberg, 16 cocontractions occurred in 8 of 15 patients. In the present study, we observed a 30% rate of cocontractions-but, most importantly, in no patient did antagonist muscle contractions inhibit agonist motion.…”

“…35 We consider that interpretation of the results reported by Carlstedt et al 34 warrants careful scrutiny, because reinnervation could have been the consequence of preserved brachial plexus elements, rather than root reimplantation. Htut et al 36 conjectured that the hands in the Carlstedt et al 34 report had been reinnervated by respiratory muscle neurons following root reimplantation. However, after a very proximal injury of the brachial plexus, the so called 'breathing hand' can result from the spontaneous regrowth of intercostal motor neurons into hand pathways.…”

Bridging defects in chronic spinal cord injury using peripheral nerve grafts combined with a chitosan-laminin scaffold and enhancing regeneration through them by co-transplantation with bone-marrow-derived mesenchymal stem cells: Case series of 14 patients

“…Clinically, motor function significantly improved after re-implanting avulsed spinal roots directly to the ventral aspect of the spinal cord. 28 Before final closure of the dura, a chitosan scaffold containing laminin as a neurite outgrowth promoting factor 14,29,30 was applied before injecting the autologous stem cells (Fig. 1J).…”

Effective reinnervation of the quadriceps femoris by spinal ventral root cross-anastomosis in rats

“…Carlstedt et al 8 founded a model for axon regeneration in the central nervous system by cut lesion in the ventral part of the spinal cord. The experiments suggested that replantation of avulsed spinal ventral roots had been shown to enable significant and useful regrowth of motor axons in both experimental animals and in human clinical cases [9][10][11][12][13][14][15] .…”