ASSESSMENT OF THE RESULTS OF ACCESSORY TO SUPRASCAPULAR NERVE TRANSFER

ABSTRACT Objective: Nerve transfers are an alternative in the reconstruction of traumatic brachial plexus injuries. In this study, we report the results of branchial plexus reconstruction using accessory to suprascapular nerve transfer. Methods: Thirty-three patients with traumatic brachial plexus injuries underwent surgical reconstruction with accessory to suprascapular nerve transfers. The patients were divided into groups in which surgery was performed either within 6 months after the injury or more than 6 months after the injury. Results were assessed using the Constant score. Results: There was no significant difference between the groups with respect to the Constant score. Conclusion: Accessory to suprascapular nerve transfer was not an efficient method for recovering active ROM or strength in the shoulder. However, it effectively improved pain control and shoulder stability. Level of evidence II, Retrospective Study.

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

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.6.peds2027 ◽

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.

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Nerve Transfer Is Superior to Nerve Grafting for Suprascapular Nerve Reconstruction in Obstetrical Brachial Plexus Birth Injury: A Meta-Analysis

Hand ◽

10.1177/15589447211030691 ◽

2021 ◽

pp. 155894472110306

Author(s):

Kevin J. Nickel ◽

Alexander Morzycki ◽

Ralph Hsiao ◽

Michael J. Morhart ◽

Jaret L. Olson

Keyword(s):

Brachial Plexus ◽

Brachial Plexus Injury ◽

External Rotation ◽

Nerve Transfer ◽

Suprascapular Nerve ◽

Cochrane Library ◽

Nerve Grafting ◽

Level Of Evidence ◽

Optimal Method ◽

Shoulder External Rotation

Background Restoration of shoulder function in obstetrical brachial plexus injury is paramount. There remains debate as to the optimal method of upper trunk reconstruction. The purpose of this study was to test the hypothesis that spinal accessory nerve to suprascapular nerve transfer leads to improved shoulder external rotation relative to sural nerve grafting. Methods A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Cochrane Library, and TRIP Pro from inception was conducted. Our primary outcome was shoulder external rotation. Results Four studies were included. Nerve transfer was associated with greater shoulder external rotation relative to nerve grafting (mean difference: 0.82 AMS 95% confidence interval [CI]: 0.27-1.36, P < .005). Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilizing procedure (odds ratio [OR]: 1.27, 95% CI: 0.8376-1.9268). Conclusion In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery. Level of Evidence Level III; Therapeutic

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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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Successful Nerve Transfers for Traumatic Brachial Plexus Palsy in a Septuagenarian

Hand ◽

10.1177/1558944715627241 ◽

2016 ◽

Vol 11 (4) ◽

pp. NP30-NP33 ◽

Cited By ~ 4

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.

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

The Professional Medical Journal ◽

10.29309/tpmj/2020.27.07.4269 ◽

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.

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

Indian Journal of Neurotrauma ◽

10.1016/s0973-0508(08)80008-1 ◽

2008 ◽

Vol 05 (02) ◽

pp. 95-104 ◽

Cited By ~ 7

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.

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Restoration of active pick-up function in patients with total brachial plexus avulsion injuries

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193417728405 ◽

2017 ◽

Vol 43 (3) ◽

pp. 269-274 ◽

Cited By ~ 5

Author(s):

Feng Li ◽

Shu-feng Wang ◽

Peng-cheng Li ◽

Yun-hao Xue ◽

Ji-yao Zou ◽

...

Keyword(s):

Brachial Plexus ◽

Elbow Flexion ◽

Suprascapular Nerve ◽

Shoulder Abduction ◽

Level Of Evidence ◽

Lower Trunk ◽

Brachial Plexus Avulsion ◽

Nerve Transfers ◽

Finger Extension ◽

Posterior Division

We designed multiple nerve transfers in one surgery to restore active pick-up function in patients with total brachial plexus avulsion injuries. Forty patients with total brachial plexus avulsion injuries first underwent multiple nerve transfers. These included transfer of the accessory nerve onto the suprascapular nerve to recover shoulder abduction, contralateral C7 nerve onto the lower trunk via the modified prespinal route with direct coaptation to restore lower trunk function and onto the musculocutaneous nerve with interpositional bridging by medial antebrachial cutaneous nerve arising from lower trunk to restore elbow flexion, and the phrenic nerve onto the posterior division of lower trunk to recover elbow and finger extension. At least three years after surgery, the patients who had a meaningful recovery were selected to perform secondary reconstruction to restore active pick-up function. Active pick-up function was successfully restored in ten patients after they underwent multiple nerve transfers combined with additional secondary functional hand reconstructions. Level of evidence: IV

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External Rotation as a Result of Suprascapular Nerve Neurotization in Obstetric Brachial Plexus Lesions

Neurosurgery ◽

10.1227/01.neu.0000170557.13788.d2 ◽

2005 ◽

Vol 57 (3) ◽

pp. 530-537 ◽

Cited By ~ 72

Author(s):

Willem Pondaag ◽

Ralph de Boer ◽

Marie S. van Wijlen-Hempel ◽

Sonja M. Hofstede-Buitenhuis ◽

Martijn J.A. Malessy

Keyword(s):

Brachial Plexus ◽

External Rotation ◽

Nerve Transfer ◽

Suprascapular Nerve ◽

Accessory Nerve ◽

Nerve Grafting ◽

Infraspinatus Muscle ◽

Significant Difference ◽

Obstetric Brachial Plexus ◽

Grafting From

ABSTRACT OBJECTIVE: Obstetric brachial plexus lesions may cause lifelong limitations of upper limb function. Nerve repair is widely advocated in infants who do not show spontaneous recovery. Typically, the suprascapular nerve (SSN) is involved in the lesion. Neurotization of the SSN routinely is performed, aiming at reinnervation of the infraspinatus muscle to restore external rotation. The results after SSN neurotization have not, as yet, been studied in detail; therefore, this study was undertaken. Of special interest was the comparison of two commonly applied SSN neurotization procedures: nerve grafting from C5 versus nerve transfer of the accessory nerve. METHODS: Infants with obstetric brachial plexus lesions after nerve grafting of C5 to the SSN (n = 65) or nerve transfer of the accessory nerve to the SSN (n = 21) were selected for retrospective analysis after a mean follow-up period of 3 years. Outcome was expressed in degrees of true glenohumeral external rotation. This was defined as the angle between the position of the 90 degrees (actively or passively) flexed elbow resting against the abdomen and the position of the flexed elbow after external rotation with the upper arm held in adduction by the investigator. This movement can be executed only by infraspinatus muscle contraction. In addition, functional external rotation was evaluated by testing the ability to reach the mouth and the back of the head. RESULTS: Only 17 (20%) of the 86 patients reached more than 20 degrees of external rotation, whereas 35 (41%) were unable to perform true external rotation. There was no statistically significant difference between nerve grafting from C5 and extraplexal nerve transfer using the accessory nerve. Functional scores showed that 88% can reach the mouth and that 75% can reach the head. CONCLUSION: The restoration of a fair range of true glenohumeral external rotation after neurotization of the SSN in infants with obstetric brachial plexus lesions, whether by grafting from C5 or by nerve transfer of the accessory nerve, is disappointingly low. However, it seems that compensatory techniques contribute to effectuate a considerable range of movement.

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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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