Multiple nerve transfers for the reanimation of shoulder and elbow functions in irreparable C5, C6 and upper truncal lesions of the brachial plexus

2008 ◽  
Vol 05 (02) ◽  
pp. 95-104 ◽  
Author(s):  
PS Bhandari ◽  
LP Sadhotra ◽  
P Bhargava ◽  
AS Bath ◽  
MK Mukherjee ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Shoulder Function ◽  
Spinal Nerve ◽  
Shoulder Abduction ◽  
Nerve Branch ◽  
Nerve Transfers

AbstractIn irreparable C5, C6 spinal nerve and upper truncal injuries the proximal root stumps are not available for grafting, hence repair is based on nerve transfer or neurotization. Between Feb 2004 and May 2006, 23 patients with irreparable C5, C6 or upper truncal injuries of the Brachial Plexus underwent multiple nerve transfers to restore the shoulder and elbow functions. Most of them (16 patients) sustained injury following motor cycle accidents. The average denervation period was 5.3 months. Shoulder function was restored by transfer of distal part of spinal accessory nerve to suprascapular nerve, and transfer of radial nerve branch to long head of triceps to the anterior branch of axillary nerve. Elbow function was restored by transfers of ulnar and median nerve fascicles to the biceps and brachialis motor branches of musculocutaneous nerve. All patients recovered shoulder abduction and external rotation; 7 scored M4 and 16 scored M3. Range of abduction averaged 1230(range, 800-1700). Full elbow flexion was restored in all 23 patients; 15 scored M4 and 8 scored M3. Patients with excellent results could lift 5 kgs of weight. Selective nerve transfers close to the target muscle provide an early and good return of functions. There is negligible morbidity in donor nerves. These intraplexal transfers are suitable in all cases of upper brachial plexus injuries.

scholarly journals Outcome of double nerve transfer close to target muscle both for shoulder abduction and elbow flexion in early C5 –C6 Brachial Plexus injury.

2020 ◽  
Vol 27 (07) ◽  
pp. 1442-1447
Author(s):  
Husnain Khan ◽  
Muhammad Shafique ◽  
Zahid Iqbal Bhatti ◽  
Tehseen Ahmad Cheema
Keyword(s):  
Brachial Plexus ◽  
Posterior Approach ◽  
Brachial Plexus Injury ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Axillary Nerve ◽  
Shoulder Abduction ◽  
Motor Branch ◽  
Nerve Transfers

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.

Results of Distal Nerve Transfers in Restoration of Shoulder Function in C5 and C6 Root Avulsion Injury to the Brachial Plexus

2017 ◽  
Vol 14 (01) ◽  
pp. 021-025
Author(s):  
Prem Bhandari
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Nerve Transfer ◽  
Shoulder Function ◽  
Shoulder Abduction ◽  
Root Avulsion ◽  
Long Thoracic Nerve ◽  
Avulsion Injury ◽  
Nerve Transfers ◽  
Distal Nerve

Background The lack of shoulder function following brachial plexus injury is a debilitating condition. Nerve root avulsion injury precludes a direct nerve repair. Under these circumstances, distal nerve transfer is a well-established technique in the restoration of shoulder abduction and external rotation. Methods Thirty patients with C5 and C6 root avulsion injury were treated with distal nerve transfers in the period between February 2009 and December 2012.The average denervation period was 5.6 months. Shoulder function was restored by posterior transfer of distal part of the spinal accessory nerve into the suprascapular nerve and transfer of the long head triceps branch of radial nerve to the anterior branch of axillary nerve. An additional nerve transfer was performed in four patients with winged scapula by transferring a part of thoracodorsal nerve into the long thoracic nerve. Results Twenty-seven patients recovered shoulder abduction; 18 scored M4 and 9 scored M3. Range of abduction averaged 118 degrees (range, 90–170 degrees). Nineteen patients restored external rotation with an average of 53 degrees (range: 30–70 degrees). Three patients failed to recover shoulder abduction though the joint regained stability. External rotation remained severely restricted in 11 patients. At final follow-up, winging of scapula improved in three of four patients following reinnervation of the serratus anterior muscle. Conclusion Nerve transfers, when performed close to the target muscles, restore good range and strength of shoulder abduction in most patients with C5 and C6 root avulsion injuries. However, return in external rotation is not as good as the recovery in abduction.

Nerve graft versus nerve transfer for neonatal brachial plexus: shoulder outcomes

2021 ◽  
Vol 27 (1) ◽  
pp. 87-92
Author(s):  
Brandon W. Smith ◽  
Kate W. C. Chang ◽  
Sravanthi Koduri ◽  
Lynda J. S. Yang
Keyword(s):  
Brachial Plexus ◽  
Clinical Data ◽  
External Rotation ◽  
Nerve Transfer ◽  
Shoulder Function ◽  
Nerve Transfers ◽  
Shoulder Flexion ◽  
Significant Difference ◽  
Transfer Strategies ◽  
Shoulder External Rotation

OBJECTIVEThe decision-making in neonatal brachial plexus palsy (NBPP) treatment continues to have many areas in need of clarification. Graft repair was the gold standard until the introduction of nerve transfer strategies. Currently, there is conflicting evidence regarding outcomes in patients with nerve grafts versus nerve transfers in relation to shoulder function. The objective of this study was to further define the outcomes for reconstruction strategies in NBPP with a specific focus on the shoulder.METHODSA cohort of patients with NBPP and surgical repairs from a single center were reviewed. Demographic and standard clinical data, including imaging and electrodiagnostics, were gathered from a clinical database. Clinical data from physical therapy evaluations, including active and passive range of motion, were examined. Statistical analysis was performed on the available data.RESULTSForty-five patients met the inclusion criteria for this study, 19 with graft repair and 26 with nerve transfers. There were no significant differences in demographics between the two groups. Understandably, there were no patients in the nerve grafting group with preganglionic lesions, resulting in a difference in lesion type between the cohorts. There were no differences in preoperative shoulder function between the cohorts. Both groups reached statistically significant improvements in shoulder flexion and shoulder abduction. The nerve transfer group experienced a significant improvement in shoulder external rotation, from −78° to −28° (p = 0.0001), whereas a significant difference was not reached in the graft group. When compared between groups, there appeared to be a trend favoring nerve transfer in shoulder external rotation, with the graft patients improving by 17° and the transfer patients improving by 49° (p = 0.07).CONCLUSIONSIn NBPP, patients with shoulder weakness experience statistically significant improvements in shoulder flexion and abduction after graft repair or nerve transfer, and patients with nerve transfers additionally experience significant improvement in external rotation. With regard to shoulder external rotation, there appear to be some data supporting the use of nerve transfers.

scholarly journals Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques

2015 ◽  
Vol 122 (1) ◽  
pp. 195-201 ◽  
Author(s):  
Zarina S. Ali ◽  
Gregory G. Heuer ◽  
Ryan W. F. Faught ◽  
Shriya H. Kaneriya ◽  
Umar A. Sheikh ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Controlled Trial ◽  
Treatment Strategies ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Surgical Approaches ◽  
Shoulder Abduction ◽  
Nerve Grafting ◽  
Nerve Transfers ◽  
Repair Techniques

OBJECT Adult upper trunk brachial plexus injuries result in significant disability. Several surgical treatment strategies exist, including nerve grafting, nerve transfers, and a combination of both approaches. However, no existing data clearly indicate the most successful strategy for restoring elbow flexion and shoulder abduction in these patients. The authors reviewed the literature to compare outcomes of the three surgical repair techniques listed above to determine the optimal approach to traumatic injury to the upper brachial plexus in adults. METHODS Both PubMed and EMBASE databases were searched for English-language articles containing the MeSH topic “brachial plexus” in conjunction with the word “injury” or “trauma” in the title and “surgery” or “repair” as a MeSH subheading or in the title, excluding pediatric articles and those articles limited to avulsions. The search was also limited to articles published after 1990 and containing at least 10 operated cases involving upper brachial plexus injuries. The search was supplemented with articles obtained through the “Related Articles” feature on PubMed and the bibliographies of selected publications. From the articles was collected information on the operation performed, number of operated cases, mean subject ages, sex distribution, interval between injury and surgery, source of nerve transfers, mean duration of follow-up, year of publication, and percentage of operative success in terms of elbow flexion and shoulder abduction of the injured limb. The recovery of elbow flexion and shoulder abduction was separately analyzed. A subanalysis was also performed to assess the recovery of elbow flexion following various neurotization techniques. RESULTS As regards the restoration of elbow flexion, nerve grafting led to significantly better outcomes than either nerve transfer or the combined techniques (F = 4.71, p = 0.0097). However, separating the Oberlin procedure from other neurotization techniques revealed that the former was significantly more successful (F = 82.82, p < 0.001). Moreover, in comparing the Oberlin procedure to nerve grafting or combined procedures, again the former was significantly more successful than either of the latter two approaches (F = 53.14; p < 0.001). In the restoration of shoulder abduction, nerve transfer was significantly more successful than the combined procedure (p = 0.046), which in turn was significantly better than nerve grafting procedures (F = 5.53, p = 0.0044). CONCLUSIONS According to data in this study, in upper trunk brachial plexus injuries in adults, the Oberlin procedure and nerve transfers are the more successful approaches to restore elbow flexion and shoulder abduction, respectively, compared with nerve grafting or combined techniques. A prospective, randomized controlled trial would be necessary to fully elucidate differences in outcome among the various surgical approaches.

Anatomic study of the intercostal nerve transfer to the suprascapular nerve and a case report

2013 ◽  
Vol 39 (2) ◽  
pp. 194-198 ◽  
Author(s):  
S. Hu ◽  
B. Chu ◽  
J. Song ◽  
L. Chen
Keyword(s):  
Case Report ◽  
Brachial Plexus ◽  
External Rotation ◽  
Nerve Transfer ◽  
Suprascapular Nerve ◽  
Intercostal Nerve ◽  
Accessory Nerve ◽  
Shoulder Abduction ◽  
Anatomical Basis ◽  
Intercostal Nerves

The purpose of this study was to investigate the anatomical basis of intercostal nerve transfer to the suprascapular nerve and provide a case report. Thoracic walls of 30 embalmed human cadavers were used to investigate the anatomical feasibility for neurotization of the suprascapular nerve with intercostal nerves in brachial plexus root avulsions. We found that the 3rd and 4th intercostal nerves could be transferred to the suprascapular nerve without a nerve graft. Based on the anatomical study, the 3rd and 4th intercostal nerves were transferred to the suprascapular nerve via the deltopectoral approach in a 42-year-old man who had had C5-7 root avulsions and partial injury of C8, T1 of the right brachial plexus. Thirty-two months postoperatively, the patient gained 30° of shoulder abduction and 45° of external rotation. This procedure provided us with a reliable and convenient method for shoulder function reconstruction after brachial plexus root avulsion accompanied with spinal accessory nerve injury. It can also be used when the accessory nerve is intact but needs to be preserved for better shoulder stability or possible future trapezius transfer.

Contralateral lower trapezius transfer for restoration of shoulder external rotation in traumatic brachial plexus palsy: a preliminary report and literature review

2013 ◽  
Vol 39 (8) ◽  
pp. 861-867 ◽  
Author(s):  
N. G. Satbhai ◽  
K. Doi ◽  
Y. Hattori ◽  
S. Sakamoto
Keyword(s):  
Brachial Plexus ◽  
Glenohumeral Joint ◽  
External Rotation ◽  
Donor Site ◽  
Nerve Transfer ◽  
Shoulder Function ◽  
No Donor ◽  
Nerve Transfers ◽  
Shoulder External Rotation ◽  
Lower Trapezius

The importance of external rotation of the shoulder is well accepted. Patients with inadequate recovery of shoulder function after nerve transfers for a brachial plexus injury have difficulty in using their reconstructed limb. The options for secondary procedures to improve shoulder function are often limited, especially if the spinal accessory nerve has been used earlier for nerve transfer or as a donor nerve for a free functioning muscle transfer. We have used the contralateral lower trapezius transfer to the infraspinatus in three cases, to restore shoulder external rotation. All patients had significant improvement in shoulder external rotation (mean 97°; range 80°–110°) and improved disability of the arm, shoulder and hand scores. The rotation occurred mainly at the glenohumeral joint, and was independent of the donor side. All patients were greatly satisfied with the outcome. Contralateral lower trapezius transfer appears to help in overall improvement of shoulder function by stabilizing the scapula. The results have remained stable after mean follow-up of 58 months (range 12–86). No donor site deficit was seen in any patient.

NERVE TRANSFER SURGERY FOR ADULT BRACHIAL PLEXUS INJURY

Neurosurgery ◽  
2009 ◽  
Vol 65 (suppl_4) ◽  
pp. A55-A62 ◽  
Author(s):  
Olawale A.R. Sulaiman ◽  
Daniel D. Kim ◽  
Clint Burkett ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Research Council ◽  
Medical Research Council ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Nerve Transfers ◽  
Direct Repair ◽  
Grade 3

Abstract OBJECTIVE To review the clinical outcomes in our patients who have undergone nerve transfer operations for brachial plexus reconstruction at the Louisiana State University (LSU) over a 10-year period. A secondary objective is to compare clinical outcomes in patients who had only nerve transfer operations as compared with patients whose nerve transfers were supplemented with direct repair of brachial plexus elements. METHODS Retrospective review of the medical records, imaging, and electrodiagnostic studies (electromyographic and nerve conduction studies) of patients with brachial plexus injuries who underwent nerve transfer operations at LSU over a period of 10 years. RESULTS A total of 81 patients were treated between 1995 to 2005 at the LSU Health Sciences Center; 7 of these patients were lost to follow-up, leaving 74 patients, with an average follow-up of 3.5 years, for review. We evaluated recovery of elbow flexion and shoulder abduction. Ninety percent of patients with medial pectoral to musculocutaneous nerve transfers recovered to LSU grade 2 (Medical Research Council grade 3), and 60% of those patients with intercostal to musculocutaneous nerve transfer regained similar strength in elbow flexion. Shoulder abduction recovery to LSU grade 2 (Medical Research Council grade 3) after spinal accessory to suprascapular and/or thoracodorsal to axillary nerve transfer, was 95% and 36%, respectively. There was a tendency for better motor recovery when nerve transfer operations were combined with direct repair of plexus elements. CONCLUSION Nerve transfers for repair of brachial plexus injuries result in excellent recovery of elbow and shoulder functions. Patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.

scholarly journals Successful Nerve Transfers for Traumatic Brachial Plexus Palsy in a Septuagenarian

Hand ◽  
2016 ◽  
Vol 11 (4) ◽  
pp. NP30-NP33 ◽  
Author(s):  
Parker H. Johnsen ◽  
Scott W. Wolfe
Keyword(s):  
Brachial Plexus ◽  
Older Patients ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
The Elderly ◽  
Suprascapular Nerve ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Post Injury ◽  
Nerve Transfers

Background: Conventional wisdom and the available literature demonstrate compromised outcomes following nerve reconstruction for traumatic brachial plexus palsy in the elderly. We present a 74-year-old male who was reconstructed with multiple nerve transfers for brachial plexus palsy after a ski accident. Methods: Triceps to axillary nerve transfer, spinal accessory to suprascapular nerve transfer, and ulnar to musculocutaneous nerve transfer were performed 16 weeks post injury. Results: At 11 years post-op, the patient could abduct to 65° and forward flex at M4 strength, limited only by painful glenohumeral arthritis. Elbow flexion was M5- at both the biceps and brachialis, and bulk and tone were nearly symmetrical with the opposite side. Eleven-year electrodiagnostic studies demonstrated reinnervation and improved motor unit recruitment all affected muscles. Conclusion: This case questions the widely held dogma that older patients who undergo brachial plexus reconstruction do poorly. Given the short reinnervation distance and optimal donor nerve health, nerve transfers may be an excellent option for healthy older patients with traumatic brachial plexus palsy.

Transfer of the Platysma Motor Branch to the Accessory Nerve in a Patient With Trapezius Muscle Palsy and Total Avulsion of the Brachial Plexus

Neurosurgery ◽  
2011 ◽  
Vol 68 (2) ◽  
pp. E567-E570 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
Motor Nerve ◽  
Trapezius Muscle ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Accessory Nerve ◽  
Shoulder Abduction ◽  
Motor Branch ◽  
Upper Trapezius

Abstract BACKGROUND AND IMPORTANCE: To report on the successful use of a platysma motor nerve transfer to the accessory nerve in a patient with concomitant trapezius and brachial plexus palsy. CLINICAL PRESENTATION: A 20-year-old man presented with total avulsion of the right brachial plexus combined with palsies of the accessory and phrenic nerve. The patient was operated on 4 months after his injury. The accessory nerve was repaired via direct transfer of the platysma motor branch. The contralateral C7 root was connected to the musculocutaneous nerve, and the hemihypoglossal nerve was grafted to the suprascapular nerve. Two intercostal nerves were attached to the triceps long head motor branch. CONCLUSION: Within 20 months of surgery, the patient regained full reinnervation of the upper trapezius muscle. Elbow flexion scored M3+, and 30° active shoulder abduction was observed. Triceps reinnervation was poor. Platysma motor branch transfer to the accessory nerve is a viable alternative to reinnervate the trapezius muscle.

scholarly journals Nerve Transfers for an Upper Brachial Plexus Injury: A Case Report

2014 ◽  
Vol 3 (01) ◽  
pp. 15-24
Author(s):  
Ferry Senjaya
Keyword(s):  
Brachial Plexus ◽  
Functional Recovery ◽  
Brachial Plexus Injury ◽  
Motor Vehicle ◽  
Motor Vehicle Accident ◽  
External Rotation ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Motor Branch ◽  
Nerve Transfers

Objective: To demonstrate multiple nerve transfers as primary surgical management for an upperplexus injury.Methods: A 6-year-old boy who suffered a preganglionic upper brachial plexus injury following a motor vehicle accident, exhibited complete biceps, deltoids, suprapinatus, and infraspinatus palsies.Multiple nerve transfers, which consist of spinal accessory nerves to suprascapular nerve transfer, median and ulnar motor fascicles to biceps and brachialis motor branches transfers, and long head oftriceps motor branch to axillary nerve transfer were performed 6 months after injury.Results: 13 months post multiple nerve transfer, the patient has regained M4+/5 elbow flexion, M4/5 external rotation, and M4/5 shoulder abduction.Conclusion: Nerve transfer is a viable option for upper plexus palsy management. With a sound surgical technique and good case selection, the results can be very rewarding. This case showedquite robust re-innervation with significant functional recovery at a one-year follow-up following multiple nerve transfers.Keywords: Brachial Plexus Injury, Upper Plexus Injury, Nerve Root Avulsion, Nerve Transfers, Functional Recovery.

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