Double-Nerve Transfer to the Axillary Nerve in Traumatic Upper Trunk Brachial Plexus Injuries Using an Axillary Approach: Anatomical Description and Preliminary Case Series

2020 ◽  
Vol 19 (2) ◽  
pp. E131-E139 ◽  
Author(s):  
Thibault Lafosse ◽  
Thibault Gerosa ◽  
Julien Serane ◽  
Michael Bouyer ◽  
Emmanuel H Masmejean ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Case Series ◽  
Nerve Transfer ◽  
Axillary Nerve ◽  
Motor Deficit ◽  
Motor Branch ◽  
Axillary Approach ◽  
Nerve Transfers ◽  
Teres Minor

Abstract BACKGROUND Restoration of shoulder external rotation remains challenging in patients with C5/C6 brachial plexus injuries (BPI). OBJECTIVE To describe a double-nerve transfer to the axillary nerve (AN), targeting both its anterior and posterior motor branches, through an axillary route. METHODS A total of 10 fresh-frozen cadaveric brachial plexuses were dissected. Using an axillary approach, the infraclavicular brachial plexus terminal branches were exposed, including the axillary, ulnar, and radial nerves. Under microscopic magnification, the triceps long head motor branch (TLHMB), anteromedial fascicles of the ulnar nerve (UF), the anterior motor branch of the axillary nerve (AAMB), and the teres minor motor branch (TMMB) were dissected and transected to simulate 2 nerve transfers, THLMB-AAMB and UF-TMMB. Several anatomical criteria were assessed, including the overlaps between fascicles when placed side-by-side. Six patients with C5/C6 BPI were then operated on using this technique. RESULTS TLHMB-AAMB and UF-TMMB transfers could be simulated in all specimens, with mean overlaps of 37.1 mm and 6.5 mm, respectively. After a mean follow-up of 23 mo, all patients had recovered grade-3 strength or more in the deltoid and teres minor muscles. Mean active shoulder flexion, abduction, and external rotation with the arm 90° abducted were of 128°, 117°, and 51°, respectively. No postoperative motor deficit was found in the UF territory. CONCLUSION A double-nerve transfer, based on radial and ulnar fascicles, appears to be an adequate option to reanimate both motor branches of the AN, providing satisfactory shoulder active elevations and external rotation in C5/C6 BPI patients.

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.

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.

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.

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.

Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results

2007 ◽  
Vol 107 (2) ◽  
pp. 370-377 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Paulo Roberto Kechele ◽  
Marcos Antonio Santos ◽  
Hamilton Duarte ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Motor Nerve ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Clinical Results ◽  
Axillary Nerve ◽  
Surgical Anatomy ◽  
Motor Branch ◽  
Nerve Transfers ◽  
Anatomical Basis ◽  
Long Head

Object Grafting or nerve transfers to the axillary nerve have been performed using a deltopectoral approach and/or a posterior arm approach. In this report, the surgical anatomy of the axillary nerve was studied with the goal of repairing the nerve through an axillary access. Methods The axillary nerve was bilaterally dissected in 10 embalmed cadavers to study its variations. Three patients with axillary nerve injuries then underwent surgical repair through an axillary access; the axillary nerve was repaired by transfer of the triceps long head motor branch. Results At the lateral margin of the subscapularis muscle, the axillary nerve was found in the center of a triangle bounded medially by the subscapular artery, laterally by the latissimus dorsi tendon, and cephalad by the posterior circumflex humeral artery. At the entrance of the quadrangular space, the axillary nerve divisions were loosely connected to each other, and could be clearly separated and correctly identified. Surgery for the axillary nerve repair through the axillary access was straightforward. Eighteen months after surgery, all three patients had recovered deltoid strength to a score of M4 on the Medical Research Council scale and had improved abduction strength by 50%. No deficit was evident in elbow extension. Conclusions The axillary nerve and its branches can be safely dissected and repaired by triceps motor nerve transfer through an axillary access.

Elbow Flexion Reconstruction in Brachial Plexus Avulsion Injuries – Results with Intercostal Nerve and Distal Nerve Transfers

2020 ◽  
Vol 25 (03) ◽  
pp. 307-314
Author(s):  
Gavrielle Hui-Ying Kang ◽  
Rebecca Qian-Ru Lim ◽  
Fok-Chuan Yong
Keyword(s):  
Brachial Plexus ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Time Interval ◽  
Success Rates ◽  
Motor Branch ◽  
Entire Cohort ◽  
Brachial Plexus Avulsion ◽  
Nerve Transfers ◽  
Distal Nerve

Background: The neural surgical options for reconstruction of elbow flexion in brachial plexus injuries depend on the availability of nerve donors. In upper-type avulsion injuries, the ulnar or median nerves, when intact, are reliable intra-plexal donor nerves for transfers to the biceps muscle. In complete avulsion injuries, donors are limited to extra-plexal sources, such as intercostal nerves (ICNs). Methods: We reviewed our results of ICN and partial distal nerve (ulnar or median) transfers for elbow flexion reconstruction in patients with brachial plexus avulsion injuries. The time taken for recovery of elbow flexion strength to M3 and the final motor outcome at 2 years were compared between both groups. Results: 38 patients were included in this study. 27 had ICN transfers to the musculocutaneous nerve (MCN), 8 had partial ulnar nerve transfers and 3 had partial median nerve transfers to the MCN's biceps motor branch. The mean time interval from injury to surgery was 3.6 months. Recovery of elbow flexion was observed earlier in the distal nerve transfer group (p < 0.05). Overall, success rates were higher in patients with distal nerve transfers (100%), compared to ICN transfers (63%) at 2 years (p = 0.018). Patients with distal nerve transfers achieved a higher final median strength of M4.0 [Interquartile range (IQR) 3.5–4.5], compared to M3.5 (IQR 2.0–4.0) in the ICN group (p = 0.031). In the subgroup of patients with upper-type brachial plexus injuries, there were no significant differences in motor outcomes between the ICN versus distal nerve transfers group. Conclusions: In our entire cohort, patients with distal nerve transfers had faster motor recovery and better elbow flexion power than patients with ICN transfers. In patients with partial brachial plexus injuries, outcomes of ICN transfers were not inferior to distal nerve transfers.

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.

scholarly journals Nerves transfers for functional hand recovery in traumatic lower brachial plexopathy

2020 ◽  
Vol 11 ◽  
pp. 358
Author(s):  
Fernando Henrique Souza ◽  
Silvya Nery Bernardino ◽  
Auricelio Batista Cezar Junior ◽  
Hugo André de Lima Martins ◽  
Isabel Nery Bernardino Souza ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
Hand Function ◽  
Case Series ◽  
Significant Loss ◽  
Plexus Brachialis ◽  
Brachial Plexopathy ◽  
Pronator Quadratus ◽  
Motor Branch ◽  
Nerve Transfers

Background: Distal nerve transfers are an innovative modality for the treatment of C8-T1 brachial plexus lesions. The purpose of this case series is to report the authors’ results with hand restoration function by nerve transfer in patients with lower brachial plexus injury. Methods: Three consecutive nerve transfers were performed in a series of 11 patients to restore hand function after injury to the lower brachial plexus: brachialis motor branch to anterior interosseous nerve (AIN) and supinator branch to the posterior interosseous nerve (PIN) in a first surgical procedure, and AIN to pronator quadratus branch of ulnar nerve between 4 and 6 months later. Results: In all, 11 male patients underwent 33 surgical procedures. Time between brachial plexus injury and surgery was a mean of 11 months (range 4–13 months). Postoperative follow-up ranged from 12 to 24 months. We observed recovery of M3 or better finger flexion strength (AIN) and wrist extension (PIN) in 8 of the 11 surgically treated upper limbs. These patients recovered full thumb and finger extension between 6 and 12 months of surgery, without significant loss of donor function. Conclusion: Nerve transfers represent a way of restoring volitional control of upper extremity function in patients with C8-T1 brachial plexus injury.

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.

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

2004 ◽  
Vol 101 (5) ◽  
pp. 770-778 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Phrenic Nerve ◽  
Cranial Nerve ◽  
External Rotation ◽  
Elbow Flexion ◽  
Content Type ◽  
Nerve Transfers ◽  
Contralateral Motor ◽  
Fine Print

Object. The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. Methods. Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90° and 92° in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70°. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3+ and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. Conclusions. Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.

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