Contralateral medial pectoral nerve transfer with free gracilis muscle transfer in old brachial plexus palsy

A child suffered a bilateral obstetric brachial plexus palsy involving the C5 and C6 nerve roots. Abduction of the shoulder joints had recovered by 1 year, but elbow flexion did not recover on either side. Free gracilis muscle transfers were performed on both sides, at an interval of 6 months, to achieve elbow flexion. The spinal accessory nerve was used as the donor nerve.

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GRACILIS MUSCLE TRANSFER TO ELBOW FLEXION IN BRACHIAL PLEXUS INJURIES

Acta Ortopédica Brasileira ◽

10.1590/1413-785220202804233021 ◽

2020 ◽

Vol 28 (4) ◽

pp. 165-167

Author(s):

Gustavo Bersani Silva ◽

Maurício Rodrigues Lima Neto ◽

Alvaro Baik Cho ◽

Raquel Bernardelli Iamaguchi ◽

Marcelo Rosa de Resende ◽

...

Keyword(s):

Muscle Strength ◽

Brachial Plexus ◽

Nerve Transfer ◽

Elbow Flexion ◽

Patient Characteristics ◽

Gracilis Muscle ◽

Muscle Transfer ◽

Level Of Evidence ◽

Late Treatment ◽

Functional Muscle Transfer

ABSTRACT Objective: Brachial plexus injury can lead to significant functional deficit for the patient. Elbow flexion restoration is a priority in surgical treatment. Free functional muscle transfer is an option for early or late treatment failure. This study evaluated patient characteristics and elbow flexion muscle strength after gracilis functioning muscle transfer. Methods: Medical records of 95 patients operated from 2003 to 2019 were analyzed and the following variables recorded: age, gender, nerve transfer used to motorize the gracilis muscle, time between trauma and surgery, age at surgery and elbow flexion strength after a minimum of 12 months following functioning muscle transfer. Results: 87 patients were included, averaging 30 years of age (17 to 57 years). Fifty-five achieved elbow flexion muscle strength ≥ M3 (55/87, 65%), with a mean follow-up of 37 months. The nerves used for activation of the transferred gracilis were: 45 spinal accessory, 10 intercostal, 8 median n. fascicles, 22 ulnar n. fascicles and 2 phrenic nerves. Conclusion: Functional muscle transfer is a viable surgical procedure for elbow flexion in chronic traumatic brachial plexus injuries in adults. Level of Evidence II, Retrospective study.

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Transfer of Pectoral Nerves to the Musculocutaneous Nerve in Obstetric Upper Brachial Plexus Palsy

Neurosurgery ◽

10.1227/01.neu.0000073420.66113.66 ◽

2003 ◽

Vol 53 (2) ◽

pp. 338-342 ◽

Cited By ~ 60

Author(s):

Gerhard Blaauw ◽

Albert C.J. Slooff

Keyword(s):

Standard Deviation ◽

Brachial Plexus ◽

Nerve Transfer ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Nerve Endings ◽

Nerve Plexus ◽

Brachial Plexus Palsy ◽

Pectoral Nerve

Abstract OBJECTIVE To investigate the results of transfer of pectoral nerves to the musculocutaneous nerve for treatment of obstetric brachial palsy. METHODS In 25 cases of obstetric brachial palsy (20 after breech deliveries), branches of the pectoral nerve plexus were transferred directly to the musculocutaneous nerve. For all patients, the nerve transfer was part of an extended brachial plexus reconstruction. Results were tested both clinically and with the Mallet scale, at a mean follow-up time of 70 months (standard deviation, 34.3 mo). RESULTS There were two complete failures, which were attributable to disconnection of the transferred nerve endings. The results after transfer were excellent in 17 cases and fair in 5 cases. Steindler flexorplasty improved elbow flexion for three patients. CONCLUSION Transfer of pectoral nerves to the musculocutaneous nerve for treatment of obstetric upper brachial palsy may be effective, if the specific anatomic features of the pectoral nerve plexus are sufficiently appreciated.

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Free functional gracilis muscle transfer in children with severe sequelae from obstetric brachial plexus palsy

Journal of Brachial Plexus and Peripheral Nerve Injury ◽

10.1186/1749-7221-3-23 ◽

2014 ◽

Vol 03 (01) ◽

pp. e122-e127 ◽

Cited By ~ 5

Author(s):

Jörg Bahm ◽

Claudia Ocampo-Pavez

Keyword(s):

Brachial Plexus ◽

Gracilis Muscle ◽

Brachial Plexus Palsy ◽

Muscle Transfer ◽

Obstetric Brachial Plexus Palsy ◽

Obstetric Brachial Plexus

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Medial pectoral nerve to musculocutaneous nerve neurotization for the treatment of persistent birth-related brachial plexus palsy: an 11-year institutional experience

Journal of Neurosurgery Pediatrics ◽

10.3171/2008.11.peds08166 ◽

2009 ◽

Vol 3 (5) ◽

pp. 348-353 ◽

Cited By ~ 24

Author(s):

John C. Wellons ◽

R. Shane Tubbs ◽

Jeffrey A. Pugh ◽

Nadine J. Bradley ◽

Charles R. Law ◽

...

Keyword(s):

Brachial Plexus ◽

Functional Recovery ◽

Traumatic Injury ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Brachial Plexus Palsy ◽

Pectoral Nerve ◽

Medial Pectoral Nerve ◽

Institutional Experience

Object Medial pectoral nerve (MPN) to musculocutaneous nerve (MCN) neurotization for recovery of elbow flexion by biceps reinnervation is a valid option following traumatic injury to the upper brachial plexus. A major criticism of the application of this technique in infants is the smaller size of the MPN and mismatch of viable axons. We describe our institutional experience utilizing this procedure and critically examine functional outcomes. Methods Office charts and hospital records of children from over an 11-year period beginning January 1997 were reviewed. Of the 53 children of various ages undergoing brachial plexus exploration for traumatic injury of any nature, 20 underwent MPN to MCN neurotization as a part of an overall procedure in the first year of life to treat birth-related brachial plexus palsy and had at least 9 months' follow-up. Medial pectoral nerve to MCN neurotization was chosen if the results of clinical examination and intraoperative electrophysiological evidence were consistent with medial cord function. Functional recovery was defined as the ability of the child to bring their hand to their mouth. Results Sixteen patients (80%) gained functional recovery. The median age at surgery was 7 months. Median time to first clinic visit documenting recovery was 11.5 months and median overall follow up was 21.5 months. Preoperative hand function was a useful predictor of recovery of elbow flexion. Conclusions Medial pectoral nerve to MCN neurotization is a valid surgical option for the reinnervation of the biceps muscle for birth-related brachial plexus palsy when the hand is functional preoperatively. Useful elbow flexion can be expected in the majority of these children.

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Nerve Transfers for Restoring Elbow Flexion in Brachial Plexus Palsy

10.5772/intechopen.98869 ◽

2021 ◽

Author(s):

Teodor Stamate ◽

Dan Cristian Moraru

Keyword(s):

Brachial Plexus ◽

Phrenic Nerve ◽

Nerve Transfer ◽

Elbow Flexion ◽

Distal Stump ◽

Brachial Plexus Palsy ◽

Nerve Transfers ◽

Pectoral Nerve ◽

Intercostal Nerves ◽

Thoracodorsal Nerve

Nerve transfers (NT) consist in sectioning a donor nerve and connecting it to the distal stump of a recipient unrepairable nerve. For elbow flexion restoration in brachial plexus palsy (BPP) we used different NT: 1) GF motor Ulnar Nerve to Biceps nerve (Oberlin technique), 2) Double fascicular median/ulnar to biceps/brachialis nerve transfer (Mackinnon), 3) InterCostal Nerves (ICN) to MCN (+/− nerve graft), 4) Medial Pectoral Nerve (MPN) to MCN, 5) ThoracoDorsal Nerve (TDN) to MCN, 6) Spinal Accessory Nerve (SAN) to MCN transfer, 7) Phrenic Nerve (PhN) to MCN, 8) Cervical Plexus C3-C4 to MCN and 9) Contralateral C7 (CC7). I want to present my personal experience using the phrenic nerve (PhN), the intercostal nerves (ICN) and Oberlin’s technique. The aim of this retrospective study is to evaluate the results of this procedure in BPP. NT is an important goal in BPP. ICN transfer into the nerve of biceps for elbow flexion recovery is a reliable procedure in BPP. ICN transfer for triceps offers a positive alternative (Carroll transposition). Oberlin technique is simple and offers better results in a shorter amount of time and is an effective and safe option.

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Intercostal and pectoral nerve transfers to re-innervate the biceps muscle in obstetric brachial plexus lesions

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193413501588 ◽

2013 ◽

Vol 39 (6) ◽

pp. 647-652 ◽

Cited By ~ 19

Author(s):

W. Pondaag ◽

M. J. A. Malessy

Keyword(s):

Brachial Plexus ◽

Nerve Transfer ◽

Intercostal Nerve ◽

Consecutive Series ◽

Biceps Muscle ◽

Nerve Transfers ◽

Pectoral Nerve ◽

Medial Pectoral Nerve ◽

Obstetric Brachial Plexus ◽

Transfer Group

In obstetric brachial plexus lesions with avulsion injury, nerve grafting for biceps muscle re-innervation may not be possible owing to the unavailability of a proximal stump. In such cases, the intercostal nerves or medial pectoral nerve can serve as donor nerves in an end-to-end transfer to the musculocutaneous nerve. The present study reports the results of both techniques from a single institution in a consecutive series of 42 patients between 1995 and 2008. From 1995 to 2000 we always used the intercostal nerve transfer, and from 2001 to 2008 both techniques were used. Biceps muscle force ≥Medical Research Council Grade 3 was achieved in 37 of 42 patients after a mean follow-up of 44 months. There was no statistical difference in the results in the medial pectoral nerve transfer group ( n = 25) and the intercostal nerve transfer group ( n = 17).

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Contralateral C7 to C7 nerve root transfer in reconstruction for treatment of total brachial plexus palsy: anatomical basis and preliminary clinical results

Journal of Neurosurgery Spine ◽

10.3171/2018.3.spine171251 ◽

2018 ◽

Vol 29 (5) ◽

pp. 491-499 ◽

Cited By ~ 6

Author(s):

Guo-Bao Wang ◽

Ai-Ping Yu ◽

Chye Yew Ng ◽

Gao-Wei Lei ◽

Xiao-Min Wang ◽

...

Keyword(s):

Brachial Plexus ◽

Nerve Root ◽

Anatomical Study ◽

Nerve Transfer ◽

Pectoralis Major ◽

Elbow Extension ◽

Brachial Plexus Palsy ◽

Pectoral Nerve ◽

Clinical Series

OBJECTIVEContralateral C7 (CC7) nerve root has been used as a donor nerve for targeted neurotization in the treatment of total brachial plexus palsy (TBPP). The authors aimed to study the contribution of C7 to the innervation of specific upper-limb muscles and to explore the utility of C7 nerve root as a recipient nerve in the management of TBPP.METHODSThis was a 2-part investigation. 1) Anatomical study: the C7 nerve root was dissected and its individual branches were traced to the muscles in 5 embalmed adult cadavers bilaterally. 2) Clinical series: 6 patients with TBPP underwent CC7 nerve transfer to the middle trunk of the injured side. Outcomes were evaluated with the modified Medical Research Council scale and electromyography studies.RESULTSIn the anatomical study there were consistent and predominantly C7-derived nerve fibers in the lateral pectoral, thoracodorsal, and radial nerves. There was a minor contribution from C7 to the long thoracic nerve. The average distance from the C7 nerve root to the lateral pectoral nerve entry point of the pectoralis major was the shortest, at 10.3 ± 1.4 cm. In the clinical series the patients had been followed for a mean time of 30.8 ± 5.3 months postoperatively. At the latest follow-up, 5 of 6 patients regained M3 or higher power for shoulder adduction and elbow extension. Two patients regained M3 wrist extension. All regained some wrist and finger extension, but muscle strength was poor. Compound muscle action potentials were recorded from the pectoralis major at a mean follow-up of 6.7 ± 0.8 months; from the latissimus dorsi at 9.3 ± 1.4 months; from the triceps at 11.5 ± 1.4 months; from the wrist extensors at 17.2 ± 1.5 months; from the flexor carpi radialis at 17.0 ± 1.1 months; and from the digital extensors at 22.8 ± 2.0 months. The average sensory recovery of the index finger was S2. Transient paresthesia in the hand on the donor side, which resolved within 6 months postoperatively, was reported by all patients.CONCLUSIONSThe C7 nerve root contributes consistently to the lateral pectoral nerve, the thoracodorsal nerve, and long head of the triceps branch of the radial nerve. CC7 to C7 nerve transfer is a reconstructive option in the overall management plan for TBPP. It was safe and effective in restoring shoulder adduction and elbow extension in this patient series. However, recoveries of wrist and finger extensions are poor.

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