Comparative Study of Nerve Grafting versus Distal Nerve Transfer for Treatment of Proximal Injuries of the Ulnar Nerve

Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper limb, presenting with disturbance of ulnar nerve sensory and motor function. The ulnar nerve may be dynamically compressed during movement, statically compressed due to reduction in tunnel volume or compliance, and tension forces may cause ischaemia or render the nerve susceptible to subluxation, further causing local swelling, compression inflammation and fibrosis. Superiority of one surgical technique for the management of CuTS has not been demonstrated. Different techniques are selected for different clinical situations with simple decompression being the most common procedure due to its efficacy and low complication rate. Adjunctive distal nerve transfer for denervated muscles using an expendable motor nerve to restore the axon population in the distal nerve is in its infancy but may provide a solution for severe intrinsic weakness or paralysis. Cite this article: EFORT Open Rev 2021;6:743-750. DOI: 10.1302/2058-5241.6.200129

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Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1676533 ◽

2018 ◽

Vol 37 (04) ◽

pp. 285-290

Author(s):

Mario Siqueira ◽

Roberto Martins ◽

Wilson Faglioni Junior ◽

Luciano Foroni ◽

Carlos Heise

Keyword(s):

Brachial Plexus ◽

Median Nerve ◽

Ulnar Nerve ◽

Traumatic Injury ◽

Surgical Techniques ◽

Nerve Transfer ◽

Elbow Flexion ◽

Nerve Transfers ◽

Significant Difference ◽

Distal Nerve

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, ± C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n = 43), or a fascicle of the median nerve (group B, n = 16) or a combination of both (group C, n = 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar + median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

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Proximal versus Distal Nerve Transfer for Biceps Reinnervation—A Comparative Study in a Rat’s Brachial Plexus Injury Model

Plastic & Reconstructive Surgery Global Open ◽

10.1097/gox.0000000000001130 ◽

2016 ◽

Vol 4 (12) ◽

pp. e1130 ◽

Cited By ~ 3

Author(s):

Aleksandra M. McGrath ◽

Johnny Chuieng-Yi Lu ◽

Tommy Naj-Jen Chang ◽

Frank Fang ◽

David Chwei-Chin Chuang

Keyword(s):

Comparative Study ◽

Brachial Plexus ◽

Brachial Plexus Injury ◽

Nerve Transfer ◽

Injury Model ◽

Distal Nerve

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Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement

Child s Nervous System ◽

10.1007/s00381-017-3492-0 ◽

2017 ◽

Vol 33 (9) ◽

pp. 1571-1574 ◽

Cited By ~ 4

Author(s):

Carlos O. Heise ◽

Mario G. Siqueira ◽

Roberto S. Martins ◽

Luciano H. Foroni ◽

Hugo Sterman-Neto

Keyword(s):

Brachial Plexus ◽

Nerve Transfer ◽

Elbow Flexion ◽

Nerve Grafting ◽

Brachial Plexus Palsy ◽

Neonatal Brachial Plexus Palsy ◽

Distal Nerve

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An Experimental Study of Contralateral C7 Root Transfer with Vascularized Nerve Grafting to Treat Brachial Plexus Root Avulsion

Journal of Hand Surgery (European Volume) ◽

10.1016/0266-7681(94)90051-5 ◽

1994 ◽

Vol 19 (1) ◽

pp. 60-66 ◽

Cited By ~ 27

Author(s):

L. CHEN ◽

Y-D. GU

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Phrenic Nerve ◽

Nerve Transfer ◽

Nerve Graft ◽

Functional Evaluation ◽

Nerve Grafting ◽

Root Avulsion ◽

Nerve Grafts ◽

Healthy Side

Experimental rat models of simulated brachial plexus injuries were devised to compare the effect of contralateral C7 root transfer with phrenic neurotization. The effect of vascularized nerve grafting (VNG) was also compared with the use of conventional nerve grafts (CNG) in the treatment of root avulsion of the brachial plexus. 160 rats were randomly divided into four groups of 40 each; contralateral C7 root transfer with a vascularized ulnar nerve graft (C7-VNG), contralateral C7 root transfer with conventional ulnar nerve grafting (C7-CNG), ipsilateral phrenic nerve transfer with a vascularized ulnar nerve graft (P-VNG) and ipsilateral phrenic nerve transfer with conventional ulnar nerve grafting (P-CNG). Electrophysiological and histological examinations and functional evaluation were performed at different post-operative intervals. C7 root transfer was found to be superior to phrenic nerve transfer and VNG superior to CNG. Severance of the C7 nerve root was not found to affect limb function on the healthy side.

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Trends in Brachial Plexus Surgery: Characterizing Contemporary Practices for Exploration of Supraclavicular Plexus

Hand ◽

10.1177/15589447211014613 ◽

2021 ◽

pp. 155894472110146

Author(s):

J. Ryan Hill ◽

Steven T. Lanier ◽

Liz Rolf ◽

Aimee S. James ◽

David M. Brogan ◽

...

Keyword(s):

Brachial Plexus ◽

Treatment Strategies ◽

Technical Difficulty ◽

Nerve Grafting ◽

Structured Interviews ◽

Lower Trunk ◽

Nerve Transfers ◽

Case Vignettes ◽

Distal Nerve

Background There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons’ rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus. Methods We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI. Results Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile. Conclusions Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.

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Transfer of a Motor Fascicle From the Ulnar Nerve to the Branch of the Radial Nerve Destined to the Long Head of the Triceps for Restoration of Elbow Extension in Brachial Plexus Surgery

Neurosurgery ◽

10.1227/neu.0b013e31822ac120 ◽

2011 ◽

Vol 70 (2) ◽

pp. E516-E520 ◽

Cited By ~ 11

Author(s):

Leandro Pretto Flores

Keyword(s):

Computed Tomography ◽

Brachial Plexus ◽

Ulnar Nerve ◽

Radial Nerve ◽

Nerve Transfer ◽

Elbow Flexion ◽

Shoulder Abduction ◽

Elbow Extension ◽

Long Head ◽

Brachial Plexus Surgery

Abstract BACKGROUND AND IMPORTANCE: Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. CLINICAL PRESENTATION: Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. CONCLUSION: The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

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