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

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>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.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>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).</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>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°).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>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.</jats:p></jats:sec>

Biomechanical analysis of brachial plexus injury: Availability of three-dimensional finite element model of the brachial plexus

“…Doi et al have reported successful outcomes with double free muscle transfer against complete avulsion of the brachial plexus ( 14 ). Bertelli et al have reported satisfactory results in abduction of the shoulder with spinal accessory nerve transfer to the suprascapular nerve in patients with complete brachial plexus injury ( 15 ). However, even though several surgical treatment options exist, perfect recovery after complete brachial plexus injury is impossible and physical difficulty is inevitable even after surgery ( 14 – 16 ).…”

Nerve Transfers in the Treatment of Peripheral Nerve Injuries

“…Results are much better with no nerve grafts interposed [17,74]. As distal injury to the SSN can be present in addition to a more proximal brachial plexus damage, some recommend to dissect the SAN as distally as possible and to make the coaptation with the SSN as close as possible to the suprascapular notch [75,76]. This transfer can be performed through an anterior or a posterior approach (Figures 2 and 3).…”

“…In some, the posterior approach is better, as a smaller part of the trapezius muscle is denervated [77,78]. Others disagree because it is technically difficult and because it cannot be done through a regular brachial plexus exploration [76], lengthening the surgical procedure [75]. The SAN should be used as a donor with caution if the serratus anterior muscle (SAM) is also paralysed for the risk of scapular winging [45].…”

Analysis of Fatty Degeneration of the Trapezius Muscle After Use of Accessory Nerve

“…3 The accessory spinal nerve is used in nerve transfers in the repair of high brachial plexus lesions and also as a motor nerve in free muscle flaps, usually with the aim of regaining shoulder and elbow function. 4,5 This is due to the fact that the accessory spinal nerve is purely motor and close to the brachial plexus in the suprascapular region. 6 It is possible to preserve function of the upper trapezius in nerve transfers, when the accessory spinal nerve is sectioned distal to the point of branching in the upper portion.…”