Surgical outcomes following nerve transfers in upper brachial plexus injuries

Abstract

Background:Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury.Materials and Methods:We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient).Results:Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).

Electrophysiological study of the dominant motor innervation to the extensor digitorum communis muscle and long head of triceps brachii at posterior divisions of brachial plexus

“…These results correspond to clinical observations in which the PDUT injuries resulted in few elbow extension deficits, 10,16 and its combined with the PDMT injury may lead to weakness of the elbow extensors. 17 …”

An anatomical study of the full-length phrenic nerve and its blood supply: clinical implications for endoscopic dissection

“…In treating traumatic brachial plexus avulsion injuries, nerve transfer involving the phrenic nerve as the donor to restore upper extremity functions has been proved to be an appropriate and effective approach that has been widely employed in many hand surgery centers, and plastic and reconstructive centers all over the world Songcharoen et al 2005;Sinis et al 2009;Bhandari et al 2009;Siqueira and Martins 2009). The application of harvesting techniques of the full-length phrenic nerve has been expanded via endoscopic thoracic surgery, which allows direct transfer to the distant impaired receptor nerves (Xu et al 2002(Xu et al , 2008, thus promising the potential of restoring forearm muscles and hand functions (Chuang and Mardini 2003).…”

A cadaveric microanatomical study of the fascicular topography of the brachial plexus

“…11,18,20,26 The success rate for surgery in brachial plexus injuries ranges from 25% to 85%, depending upon whether they are partial-or pan-plexal injuries. 3,12,20,27 Surgery is indicated in cases of the absence of signs of regeneration, even after 3-4 months of injury. 11,13 There is no standard treatment strategy that suits all patients, and an individualistic approach is preferred in the treatment of these lesions.…”

“…These modalities consist of either neurolysis, or intra/extraplexal nerve transfer (neurotization), with or without a nerve graft. 3,11,12,26,27 Two factors play a major role in functional recovery after the repair of a nerve lesion. 24 The first factor is the number of axons that successfully cross the anastomotic site.…”

“…2,13,14,16 Recently introduced nerve transfer techniques selectively neurotize target muscles close to motor endplates and produce early and consistently good results, especially in the management of upper truncal injuries. 3,15,21,32 The management of brachial plexus injuries involves a combination of comprehensive care, cross-specialty consultations, prolonged hours of surgery, and a protracted period of pre-and postoperative physiotherapy. Even then, the results of surgery may not be favorable.…”