Nerve Reconstruction and Tendon Transfers for Treatment of Brachial Plexus Injuries

The complexity of each brachial plexus injury (BPI) pattern and physiologic limitations of nerve regeneration create challenges for BPI patients and their surgeons. Detailed assessment via physical examination, electrodiagnostic studies, and advanced imaging can aid the surgeon in predicting the prognosis for each patient’s neurologic recovery and provide an outline for reconstructive priorities. Surgical exploration of the brachial plexus confirms the injury pattern and guides the overall treatment strategies. A multimodal reconstructive strategy including nerve grafting, extraplexal nerve transfers, distal intraplexal nerve transfers, and free-functioning muscle transfers is designed for each patient to accomplish the goals of providing a pain-free helper hand. Additional reconstructive procedures such as tendon transfers and selective joint arthrodeses are used after the results of the initial reconstructive efforts have been declared. Beyond the neurologic components of BPI, the surgeon must be attuned to the social and psychological sequelae of this devastating injury. This review contains 10 figures, 1 table, and 60 references. Key Words: brachial plexus injury, elbow flexion, free-functioning muscle transfer, nerve grafting, nerve transfer, reconstruction, shoulder abduction, , tendon transfer

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

Journal of Neurosurgery ◽

10.3171/2014.9.jns132823 ◽

2015 ◽

Vol 122 (1) ◽

pp. 195-201 ◽

Cited By ~ 48

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.

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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 Triceps Motor Branches of the Radial Nerve to the Axillary Nerve with or without other Nerve Transfers Provides Antigravity Shoulder Abduction in Pediatric Brachial Plexus Injury

Hand ◽

10.1007/s11552-012-9398-0 ◽

2012 ◽

Vol 7 (2) ◽

pp. 186-190 ◽

Cited By ~ 14

Author(s):

Matthew C. McRae ◽

Gregory H. Borschel

Keyword(s):

Brachial Plexus ◽

Radial Nerve ◽

Brachial Plexus Injury ◽

Axillary Nerve ◽

Shoulder Abduction ◽

Nerve Transfers

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A Systematic Review of Nerve Transfer and Nerve Repair for the Treatment of Adult Upper Brachial Plexus Injury

Neurosurgery ◽

10.1227/neu.0b013e318257be98 ◽

2012 ◽

Vol 71 (2) ◽

pp. 417-429 ◽

Cited By ~ 73

Author(s):

Lynda J.-S. Yang ◽

Kate W.-C. Chang ◽

Kevin C. Chung

Keyword(s):

Brachial Plexus ◽

Scale Score ◽

Brachial Plexus Injury ◽

Nerve Repair ◽

Nerve Transfer ◽

Elbow Flexion ◽

Shoulder Abduction ◽

Nerve Reconstruction ◽

Operative Exploration ◽

Significant Difference

Abstract Nerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion.

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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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Shoulder Arthrodesis for Traumatic Brachial Plexus Injuries: Functional Outcomes and Complications

Hand ◽

10.1177/1558944721998008 ◽

2021 ◽

pp. 155894472199800

Author(s):

Alvaro Baik Cho ◽

Helio Jiseok Choi ◽

Carlos Henrique Vieira Ferreira ◽

Leandro Yoshinobu Kiyohara ◽

Gustavo Bersani Silva ◽

...

Keyword(s):

Brachial Plexus ◽

Brachial Plexus Injury ◽

External Rotation ◽

Therapeutic Option ◽

Functional Results ◽

Shoulder Abduction ◽

Subacromial Space ◽

Nerve Reconstruction ◽

The Mean ◽

Shoulder Arthrodesis

Background The external rotation and abduction of shoulder are considered one of the priorities of reconstruction in brachial plexus injury. The aim of this study was to evaluate the functional results and complications of shoulder arthrodesis in patients with brachial plexus injury to better comprehend the benefits of this procedure. Methods Between 2015 and 2019, 15 shoulder arthrodesis were performed in patients with long-standing brachial plexus injury. The main indication for arthrodesis was absent or poor recovery of shoulder abduction and external rotation. Patients presented different levels of injury. Shoulder measurements of active abduction and external rotation were made based on image records of the patients. A long 4.5-mm reconstruction plate was fit along the scapular spine, acromion, and lateral proximal third of the humerus. Structured bone graft was fit into the subacromial space. Results The mean preoperative abduction was 16°, and the mean postoperative abduction was 42°. The mean preoperative external rotation was −59°, and the mean postoperative external rotation was −13°. The mean increase in abduction and external rotation was 25° and 45°, respectively. Bone union was achieved in all cases at an average time of 5.23 months. We experienced humeral fractures in 26.66% of the cases, which were all successfully treated nonoperatively. Conclusions Shoulder arthrodesis is a rewarding procedure for patients with brachial plexus injuries. A marked improvement in the upper limb positioning was observed in all patients. It should be considered as the main therapeutic option in cases where nerve reconstruction is no longer possible.

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