Posterior approach technique for accessory-suprascapular nerve transfer: A cadaveric study of the anatomical landmarks and number of myelinated axons

Adult brachial plexus injury is a now a common problem due to high incidence of motorbike accidents. Among all types, C 5 and C6 (upper brachial plexus injury) is the most common. If the patient present within 6 months then nerve transfer is the preferred treatment. However, there are different options for nerve transfer and different approaches for surgery. Objectives: The objective of the study was to share our experience of nerve transfer close to target muscles in upper brachial plexus injury. Study Design: Quaisi experimental study. Setting: National Orthopaedic Hospital, Bahawalpur. Period: January 2015 to June 2018. Material & Methods: Total 32 patients were operated with isolated C5 and C6 injury. In all patients four nerve transfers were done. For shoulder abduction posterior approach was used and accessory to suprascapular nerve and one of motor branch of radial to axillary nerve were transferred. Modified Oberlin transfer was done for elbow flexion. Both shoulder abduction and elbow flexion was graded according to medical research council grading system. Results: After one year follow up more than 75% of the patients showed good to normal shoulder abduction and 87.50% showed good to normal elbow flexion. Residual Median nerve damage was noted only in two patients (6.25%). Conclusion: If there is no evidence of recovery up to three months early nerve transfer should be considered, ideal time is 3-6 months. Nerve transfer close to target muscle yields superior results. The shoulder stabilizers and abductors should ideally be innervated by double nerve transfer through posterior approach. Similarly double fascicular transfer (modified Oberlin) should be done for elbow flexion.

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Pathological findings identified during the posterior approach to the spinal accessory nerve after high-energy trauma

Journal of Hand Surgery (European Volume) ◽

10.1177/17531934211039698 ◽

2021 ◽

pp. 175319342110396

Author(s):

Dominic M. Power ◽

Devanshi Jimulia ◽

Paul Malone ◽

Colin Shirley ◽

Tahseen Chaudhry

Keyword(s):

Anterior Approach ◽

Posterior Approach ◽

Nerve Transfer ◽

Suprascapular Nerve ◽

High Energy ◽

Pathological Findings ◽

Level Of Evidence ◽

Suprascapular Notch ◽

High Energy Trauma ◽

Spinal Accessory

The spinal accessory to suprascapular nerve transfer is a key procedure for restoring shoulder function in upper brachial plexus injuries and is typically undertaken via an anterior approach. The anterior approach may miss injury to the suprascapular nerve about the suprascapular notch, which may explain why functional outcomes are often limited. In 2014 we adopted a posterior approach to enable better visualization of the suprascapular nerve at the notch. Over the next 6 years we have used this approach for 20 explorations after high-energy trauma. In 7/20 we identified abnormalities at the level of the suprascapular ligament, which we would not have identified with an anterior approach: there were two ruptures, two neuromas-in-continuity and three cases of scar encasement, necessitating neurolysis. Nerve transfer could be undertaken distal to the suprascapular notch, bypassing the site of injury. These pathological findings support the wider adoption of the posterior approach in cases of high-energy trauma. Level of evidence: IV

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Traumatic Suprascapular Nerve Injury at the Notch—A Reason for the Posterior Approach in Brachial Plexus Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0037-1603736 ◽

2017 ◽

Vol 33 (08) ◽

pp. 592-595

Author(s):

Marc Seifman ◽

Scott Ferris

Keyword(s):

Brachial Plexus ◽

Posterior Approach ◽

External Rotation ◽

Nerve Transfer ◽

Suprascapular Nerve ◽

Shoulder Function ◽

Senior Author ◽

Spinal Accessory Nerve ◽

Accessory Nerve ◽

Spinal Accessory

Background Optimal dynamic reconstruction of shoulder function requires a functional suprascapular nerve (SSN). Nerve transfer of the distal spinal accessory nerve (dSAN) to the SSN will in many cases restore very good supraspinatus and infraspinatus function. One potential cause of failure of this nerve transfer is an unrecognized more distal injury of the SSN. An anterior approach to this transfer does not allow for visualization of the nerve at the scapular notch which is a disadvantage when compared with a posterior approach to the SSN. Methods All patients of the senior author (S.F.) with traumatic brachial plexus injuries undergoing spinal accessory nerve to SSN transfer via the posterior approach were analyzed. Results Of the 58 patients, 11 (19.0%) demonstrated abnormal findings at the notch. In two of these 11 patients (18.2%), reconstruction was abandoned due to severe injury of the nerve. There was a higher rate of clavicular fractures in patients with SSN injuries at the notch, compared with no SSN injury at the notch (63.6 vs. 12.8%). Conclusion The dSAN to SSN transfer is a reliable reconstruction for restoration of shoulder external rotation and abduction. There is a high proportion of injuries to the nerve at the notch, which can be best appreciated from a posterior approach. The authors, therefore, advocate a posterior approach for this nerve transfer.

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Posterior approach for accessory-suprascapular nerve transfer: an electrophysiological outcomes study

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193412447495 ◽

2012 ◽

Vol 38 (3) ◽

pp. 242-247 ◽

Cited By ~ 12

Author(s):

J. Rui ◽

X. Zhao ◽

Y. Zhu ◽

Y. Gu ◽

J. Lao

Keyword(s):

Anterior Approach ◽

Posterior Approach ◽

Nerve Transfer ◽

Suprascapular Nerve ◽

Significant Difference ◽

Potential Alternative ◽

Motor Unit Action ◽

Low Incidence ◽

Electrophysiological Examination ◽

Approach Group

The aim of this study was to retrospectively investigate the electrophysiological results obtained after employing the posterior approach for spinal accessory nerve-suprascapular nerve (SAN-SSN) transfer, and to compare this with the traditional anterior approach. SAN-SSN transfer was performed in 74 patients with brachial plexus injury. The posterior approach was used in 35 patients and the anterior approach was used in 39 patients. Electrophysiological examination was conducted and analyzed postoperatively. There was no significant difference between approaches in the time it took for the infraspinatus to show low-incidence motor unit action potentials (MUAPs) and an incomplete interference pattern. In addition, the final ratio of patients that showed regeneration potential of the infraspinatus was not significantly different between the approaches. Furthermore, latency and wave amplitude showed a linear regression with post-operative time in the posterior approach group. In the posterior approach group, the final abduction of the shoulder was positively correlated with the amplitude. The posterior approach for SAN-SSN is an effective potential alternative technique that may be appropriate for some clinical situations.

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Anatomical feasibility of peripheral nerve transfer to reestablish external anal sphincter control – cadaveric study

Surgical and Radiologic Anatomy ◽

10.1007/s00276-020-02635-z ◽

2021 ◽

Author(s):

Andrea Povedano ◽

Rosana Siqueira Brown ◽

Daniel A. N. Barbosa ◽

Rossano Kepler Alvim Fiorelli ◽

Fernando Guedes

Keyword(s):

Peripheral Nerve ◽

Anal Sphincter ◽

External Anal Sphincter ◽

Nerve Transfer ◽

Cadaveric Study

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Distal nerve transfer from the median nerve lumbrical fibers to the distal ulnar nerve motor branches in the palm: An anatomical cadaveric study

Microsurgery ◽

10.1002/micr.30402 ◽

2018 ◽

Vol 39 (5) ◽

pp. 434-440

Author(s):

Michele R. Colonna ◽

Davide Pino ◽

Bruno Battiston ◽

Francesco Stagno d'Alcontres ◽

Konstantinos Natsis ◽

...

Keyword(s):

Median Nerve ◽

Ulnar Nerve ◽

Nerve Transfer ◽

Cadaveric Study ◽

Distal Nerve

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Accessory Nerve to Suprascapular Nerve Transfer to Restore Shoulder Exorotation in Otherwise Spontaneously Recovered Obstetric Brachial Plexus Lesions

Neurosurgery ◽

10.1227/01.neu.0000232988.46219.e4 ◽

2006 ◽

Vol 59 (4) ◽

pp. 858-869 ◽

Cited By ~ 20

Author(s):

Willem J.R. van Ouwerkerk ◽

Bernard M.J. Uitdehaag ◽

Rob L.M. Strijers ◽

Frans Nollet ◽

Kurt Holl ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Brachial Plexus ◽

Spontaneous Recovery ◽

Nerve Transfer ◽

Suprascapular Nerve ◽

Resonance Imaging ◽

Obstetric Brachial Plexus ◽

Plexus Lesion

Abstract OBJECTIVE: A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation. METHODS: In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated. RESULTS: Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations. CONCLUSION: An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.

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Evaluation of suprascapular nerve neurotization after nerve grafting or transfer in the treatment of brachial plexus traction lesions

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.14 ◽

2004 ◽

Vol 16 (5) ◽

pp. 1-13

Author(s):

Martijn J. A. Malessy ◽

Godard C. W. de Ruiter ◽

Kees S. de Boer ◽

Ralph T. W. M. Thomeer

Keyword(s):

Brachial Plexus ◽

Muscle Power ◽

Nerve Transfer ◽

Deltoid Muscle ◽

Suprascapular Nerve ◽

Shoulder Function ◽

Axillary Nerve ◽

Infraspinatus Muscle ◽

Function Recovery ◽

Grade 3

Object The aim of this retrospective study was to evaluate the restoration of shoulder function by means of supra-scapular nerve neurotization in adult patients with proximal C-5 and C-6 lesions due to a severe brachial plexus traction injury (BPTI). The primary goal of brachial plexus reconstructive surgery was to restore the biceps muscle function and, secondarily, to reanimate shoulder function. Methods Suprascapular nerve neurotization was performed by grafting the C-5 nerve in 24 patients and by accessory or hypoglossal nerve transfer in 29 patients. Additional neurotization involving the axillary nerve could be performed in 18 patients. Postoperative needle electromyography studies of the supraspinatus, infraspinatus, and deltoid muscles showed signs of reinnervation in most patients; however, active glenohumeral shoulder function recovery was poor. In nine (17%) of 53 patients supraspinatus muscle strength was Medical Research Council (MRC) Grade 3 or 4 and in four (8%) infraspinatus muscle power was Grade 3 or 4. In 18 patients in whom deltoid muscle reinnervation was attempted, MRC Grade 3 or 4 function was demonstrated in two (11%). In the overall group, eight patients (15%) exhibited glenohumeral abduction with a mean of 44 ± 17° (standard deviation [SD]) (median 45°) and four patients (8%) exhibited glenohumeral exorotation with a mean of 48 ± 24° (SD) (median 53°). In only three patients (6%) were both functions regained. Conclusions The reanimation of shoulder function in patients with proximal C-5 and C-6 BPTIs following supra-scapular nerve neurotization is disappointingly low.

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