Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve

Bertelli, Jayme Augusto; Ghizoni, Marcos Flávio

doi:10.1016/j.jhsa.2003.10.013

Cited by 258 publications

(196 citation statements)

References 22 publications

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“…The success of triceps to axillary nerve transfers in brachial plexus injuries has been well documented (11,17,18). Our results show that with this transfer, functional deltoid strength is recovered (3.4/5).…”

Section: Discussionsupporting

confidence: 59%

Nerve transfers for treatment of isolated axillary nerve injuries

Wheelock¹,

Clark²,

Giuffre³

2015

CAN J PLAST SURG

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Shoulder dislocations are the most common major joint dislocations in the human skeleton, accounting for up to 45% of all dislocations (1). Several injuries associated with anterior glenohumeral dislocations include neurological defects, rotator cuff injuries and fractures of the greater tuberosity (2). These injuries can influence immediate recovery of function or reduce functional reserve, leading to upper extremity disability with subsequent injury. In a large-scale study of anterior glenohumeral dislocations by Robinson et al (2), 5.8% (210 of 3633 patients) were found to have an associated neurological injury and 7.8% (282 of 3633 patients) had combined injuries (neurological injury and either rotator cuff injury or greater tuberosity fracture). The most common neurological deficit following an anterior glenohumeral dislocation is an isolated axillary nerve injury. While most recover spontaneously over the subsequent three to four months, some experience persistent axillary neuropathy.The axillary nerve innervates the deltoid and teres minor muscles, which provide humeral stability within the glenoid fossa, shoulder external rotation and shoulder abduction. The axillary nerve also enables sensation over the lateral shoulder. Both the rotator cuff and deltoid muscles contribute to shoulder abduction: the rotator cuff muscles are more effective abductors at low abduction angles (0° to 30°) and the deltoid at higher abduction angles (>30˚) (3). The functional deficit in a patient with an axillary neuropathy depends on nerve recovery, associated rotator cuff injuries and the patient's premorbid rotator cuff function. Individuals with intact rotator cuffs may be able to compensate for the axillary nerve dysfunction; however, without the deltoid, their shoulder fatigues easily, limiting their activities. Additionally, sole reliance on the rotator cuff may be problematic in later years, given high rates of partial or complete rotator cuff tears in the aging population (4,5).Management of persistent axillary neuropathy has traditionally consisted of axillary nerve grafting, with 73% to 88% of patients regaining useful deltoid strength (6-9). Success of this procedure is dependent on the length of graft required, determination of the distal extent of the axillary nerve injury and has the added donor-site morbidity. Triceps branch to axillary nerve transfer was originally described by Leechavenvongs et al (10) for C5 and C6 brachial plexus injuries. This transfer has been effective for restoring shoulder abduction, external rotation and stability. It has the advantages of a single neurorrhaphy in close proximity to the target muscle and a single operative site. BACKGROUND:The most common neurological defect in traumatic anterior glenohumeral dislocation is isolated axillary nerve palsy. Most recover spontaneously; however, some have persistent axillary neuropathy. An intact rotator cuff may compensate for an isolated axillary nerve injury; however, given the high rate of rotator cuff pathology with advancing age, pa...

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Section: Discussionsupporting

confidence: 59%

Nerve transfers for treatment of isolated axillary nerve injuries

Wheelock¹,

Clark²,

Giuffre³

2015

CAN J PLAST SURG

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“…Bertelli reported on 10 patients with transfer of a branch of the radial nerve to the axillary nerve with average shoulder abduction of 92° (range: 65-120°) with only three of 10 patients obtaining M4 strength. 4 Again, in our study final shoulder abduction was 84.5° (0-160°), average postoperative deltoid strength was 2.8 (0-5) with five of 12 patients (41.7%) achieved at least M4 strength and eight of 12 patients (66.7%) achieved at least M3 strength. Our results were more similar to Bertelli's.…”

Section: Discussionsupporting

confidence: 48%

“…1 Among these, transfer of a branch of the radial nerve to the axillary nerve has shown promising results for restoring deltoid strength and shoulder abduction. [2][3][4] The purpose of this study was to review our experience in restoring deltoid strength and shoulder abduction by neurotization of a branch of the radial nerve (Fig. 2) to the axillary nerve, as described by Leechavenvongs, 3,5 in patients with a brachial plexus or axillary nerve injury resulting from trauma or shoulder arthroplasty.…”

Section: Introductionmentioning

confidence: 99%

Restoration of Shoulder Abduction after Radial to Axillary Nerve Transfer following Trauma or Shoulder Arthroplasty

Nunley¹,

Leversedge²,

Wray³

et al. 2013

The Duke Orthopaedic Journal

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Purpose: A loss of active shoulder abduction due to axillary nerve dysfunction may be caused by brachial plexus or isolated axillary nerve injury and is often associated with a severe functional deficit. The purpose of this study was to evaluate retrospectively the restoration of deltoid strength and shoulder abduction after transfer of a branch of the radial nerve to the axillary nerve for patients who had sustained an axillary nerve injury. Materials and methods:We retrospectively reviewed all patients who underwent transfer of a branch of the radial nerve to the anterior branch of the axillary nerve at our institution, either alone or in combination with other nerve transfers, between 2004 and 2011. We identified, by chart review, 12 patients with an average follow-up of 16.7 months (6-36 months) who met inclusion criteria.Results: Active shoulder abduction significantly improved from an average of 9.6° (0-60°) to 84.5° (0-160°) (p < 0.005). Average initial deltoid strength significantly improved from 0.3 (0-2) on the M scale to an average postoperative deltoid strength of 2.8 (0-5) (p < 0.005). Five of 12 (41.7%) achieved at least M4 strength and eight of 12 (66.7%) achieved at least M3 strength. No statistically significant difference was seen when subgroup analysis was performed for isolated nerve transfer vs multiple nerve transfer, mechanism of injury with MVC vs shoulder arthroplasty, age, branch of radial nerve transferred, or time from injury to surgery. No significant change in triceps strength was observed with an average of 4.9 (4-5) strength preoperatively and 4.8 (4-5) postoperatively (p = 0.34). There were three patients who achieved no significant gain in shoulder abduction or deltoid strength for unknown reasons. Conclusion:Transfer of a branch of the radial nerve to the anterior branch of the axillary nerve is successful in improving deltoid strength and shoulder abduction in most patients. Our series, the largest North American series to our knowledge, has not shown outcomes as favorable as other series. Larger multicenter trials are needed.Type of study/Level of evidence: This is a retrospective case series representing a level IV study.

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“…Following the description of Kawabata and colleagues [9] of the use of the spinal accessory nerve as an ipsilateral nerve transfer to the suprascapular nerve in infants with upper brachial plexus birth injuries, its use has continued to expand. Total the scores for active abduction/forward flexion and active external rotation; from [7] a Maximum shoulder score=10; decrease score by 1 point for a contracture >20°T Several groups [1,6,8,11,14,19,20] have published variable experiences with the use of the distal SAN-to-SSN transfer as part of a primary or secondary plexus reconstruction in infants who fail to demonstrate spontaneous recovery of active shoulder external rotation following a period of observation. In a retrospective review of 86 infants, Pondaag et al [14] found similar clinical results and functional scores in infants undergoing C5-to-SSN bypass grafting (n=65) and those who received direct SANto-SSN (n=21) transfers performed at a mean of 5 months of age.…”

Section: Discussionmentioning

confidence: 99%

Outcome Following Spinal Accessory to Suprascapular (Spinoscapular) Nerve Transfer in Infants with Brachial Plexus Birth Injuries

Ruchelsman

Ramos

Alfonso

et al. 2009

Hand (New York, N,Y.)

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The purpose of this study is to evaluate the value of distal spinal accessory nerve (SAN) transfer to the suprascapular nerve (SSN) in children with brachial plexus birth injuries in order to better define the application and outcome of this transfer in these infants. Over a 3-year period, 34 infants with brachial plexus injuries underwent transfer of the SAN to the SSN as part of the primary surgical reconstruction. Twenty-five patients (direct repair, n=20; interposition graft, n=5) achieved a minimum follow-up of 24 months. Fourteen children underwent plexus reconstruction with SAN-to-SSN transfer at less than 9 months of age, and 11 underwent surgical reconstruction at the age of 9 months or older. Mean age at the time of nerve transfer was 11.6 months (range, 5-30 months). At latest follow-up, active shoulder external rotation was measured in the arm abducted position and confirmed by review of videos. The Gilbert and Miami shoulder classification scores were utilized to report shoulder-specific functional outcomes. The effects of patient age at the time of nerve transfer and the use of interpositional nerve graft were analyzed. Overall mean active external rotation measured 69.6°; mean Gilbert score was 4.1 and the mean Miami score was 7.1, corresponding to overall good shoulder functional outcomes. Similar clinical and shoulder-specific functional outcomes were obtained in patients undergoing early (<9 months of age, n=14) and late (>9 months of age, n=11) SAN-to-SSN transfer and primary plexus reconstruction. Nine patients (27%) were lost to follow-up and are not included in the analysis. Optimum results were achieved following direct transfer (n=20). Results following the use of an interpositional graft (n=5) were rated satisfactory. No patient required a secondary shoulder procedure during the study period. There were no postoperative complications. Distal SAN-to-SSN (spinoscapular) nerve transfer is a reliable option for shoulder reinnervation in infants with brachial plexus birth injuries. Direct transfer seems to be the optimum method. The age of the patient does not seem to significantly impact on outcome.

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Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve

Cited by 258 publications

References 22 publications

Nerve transfers for treatment of isolated axillary nerve injuries

Nerve transfers for treatment of isolated axillary nerve injuries

Restoration of Shoulder Abduction after Radial to Axillary Nerve Transfer following Trauma or Shoulder Arthroplasty

Outcome Following Spinal Accessory to Suprascapular (Spinoscapular) Nerve Transfer in Infants with Brachial Plexus Birth Injuries

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