Anatomical feasibility of transferring supinator motor branches to the posterior interosseous nerve in C7–T1 brachial plexus palsies

2009 ◽  
Vol 111 (2) ◽  
pp. 326-331 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Paulo Roberto Kechele ◽  
Marcos Antonio Santos ◽  
Bruno Adler Maccagnan Pinheiro Besen ◽  
Hamilton Duarte
Keyword(s):  
Brachial Plexus ◽  
Muscle Function ◽  
Histological Study ◽  
Posterior Interosseous Nerve ◽  
Nerve Transfers ◽  
Finger Extension ◽  
Distal Side ◽  
Finger Flexion ◽  
Supinator Muscle ◽  
Motor Nerves

Object In C7–T1 palsies of the brachial plexus, shoulder and elbow function is preserved, but finger motion is absent. Finger flexion has been reconstructed using tendon or nerve transfers. Finger extension has been restored ineffectively by attaching the extensor tendons to the distal side of the dorsal radius (that is, tenodesis). In these types of nerve palsy, supinator muscle function is preserved because innervation stems from the C-6 root. In the present study, the authors investigated the anatomy and the feasibility of transferring the supinator motor branches to the posterior interosseous nerve. Sacrifice of the supinator motor branches does not abolish supination because biceps muscle function is preserved in lower-type injuries of the brachial plexus. Methods The posterior interosseous nerve was dissected in 20 formalin-fixed forearms. Through posterior forearm access, the posterior interosseous nerve and its motor branches to the supinator muscle were dissected. Specimens were removed for histological study. Results In the vicinity of the supinator muscle's proximal margin (that is, the Frohse arcade), 2 nerve branches arose laterally and medially from the posterior interosseous nerve to innervate the superficial and deep heads of the supinator muscle, respectively. The supinator motor nerves, when divided, could be coapted directly to the posterior interosseous nerve. The number of myelinated fibers in the supinator motor branches corresponded to 70% that of the posterior interosseous nerve. Conclusions The supinator motor nerves can be transferred directly to the posterior interosseous nerve to restore thumb and finger extension in patients with C7–T1 brachial plexus lesions.

Transfer of supinator motor branches to the posterior interosseous nerve in C7–T1 brachial plexus palsy

2010 ◽  
Vol 113 (1) ◽  
pp. 129-132 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flavio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
Index Finger ◽  
Motor Nerve ◽  
Anatomical Study ◽  
Nerve Transfer ◽  
Posterior Interosseous Nerve ◽  
Lateral Aspect ◽  
Finger Extension ◽  
Finger Flexion ◽  
Finger Motion

Object In C7–T1 palsies of the brachial plexus, shoulder and elbow function are preserved, but finger motion is absent. Finger flexion has been reconstructed by tendon or nerve transfers. Finger extension has been restored ineffectively by attaching the extensor tendons to the distal aspect of the dorsal radius (termed tenodesis) or by tendon transfers. In these palsies, supinator muscle function is preserved, because innervation stems from the C-6 root. The feasibility of transferring supinator branches to the posterior interosseous nerve has been documented in a previous anatomical study. In this paper, the authors report the clinical results of supinator motor nerve transfer to the posterior interosseous nerve in 4 patients with a C7–T1 root lesion. Methods Four adult patients with C7–T1 root lesions underwent surgery between 5 and 7 months postinjury. The patients had preserved motion of the shoulder, elbow, and wrist, but they had complete palsy of finger motion. They underwent finger flexion reconstruction via transfer of the brachialis muscle, and finger and thumb extension were restored by transferring the supinator motor branches to the posterior interosseous nerve. This nerve transfer was performed through an incision over the proximal third of the radius. Dissection was carried out between the extensor carpi radialis brevis and the extensor digitorum communis. The patients were followed up as per regular protocol and underwent a final evaluation 12 months after surgery. To document the extent of recovery, the authors assessed the degree of active metacarpophalangeal joint extension of the long fingers. The thumb span was evaluated by measuring the distance between the thumb pulp and the lateral aspect of the index finger. Results Surgery to transfer the supinator motor branches to the posterior interosseous nerve was straightforward. Twelve months after surgery, all patients were capable of opening their hand and could fully extend their metacarpophalangeal joints. The distance of thumb abduction improved from 0 to 5 cm from the lateral aspect of the index finger. Conclusions Transferring supinator motor nerves directly to the posterior interosseous nerve is effective in at least partially restoring thumb and finger extension in patients with lower-type injuries of the brachial plexus.

Clinical use of supinator motor branch transfer to the posterior interosseous nerve in C7–T1 brachial plexus palsies

2010 ◽  
Vol 113 (1) ◽  
pp. 113-117 ◽  
Author(s):  
Zhen Dong ◽  
Yu-Dong Gu ◽  
Cheng-Gang Zhang ◽  
Lei Zhang
Keyword(s):  
Brachial Plexus ◽  
Reliable Method ◽  
Nerve Transfer ◽  
Posterior Interosseous Nerve ◽  
Viable Option ◽  
Motor Branch ◽  
Finger Extension ◽  
Finger Flexion ◽  
Anterior Interosseous Nerve

Object In C7–T1 brachial plexus palsies, finger extension and flexion are absent. At the authors' institution, finger flexion has been successfully reconstructed by transferring the brachialis motor branch to the anterior interosseous nerve. However, there is no reliable method for restoring finger extension. In the present study, the authors examined the surgical results of transferring the supinator motor branch to the posterior interosseous nerve. Methods Since October 2007, the authors have performed a supinator motor branch transfer to the posterior interosseous nerve in 4 patients. The patients underwent follow-up every 3–4 months postoperatively. Results Finger extension appeared between 5 and 9 months in the first 3 cases and demonstrated promising improvement over time. One recent case remains under follow-up. Conclusions A supinator motor branch to posterior interosseous nerve transfer leads to reliable recovery of thumb and finger extension. Therefore, it is a viable option for C7–T1 brachial plexus palsies.

Supinator to Posterior Interosseous Nerve Transfer for Restoration of Finger Extension

2021 ◽  
Author(s):  
Stanley Bazarek ◽  
Margaret Sten ◽  
Darren Nin ◽  
Justin M Brown
Keyword(s):  
Spinal Cord ◽  
Brachial Plexus ◽  
Spinal Cord Injuries ◽  
Brachial Plexus Injury ◽  
Cervical Spinal Cord ◽  
Nerve Transfer ◽  
Posterior Interosseous Nerve ◽  
Loss Of Function ◽  
Finger Extension ◽  
Supinator Muscle

Abstract BACKGROUND Cervical spinal cord injuries result in a severe loss of function and independence. The primary goal for these patients is the restoration of hand function. Nerve transfers have recently become a powerful intervention to restore the ability to grasp and release objects. The supinator muscle, although a suboptimal tendon transfer donor, serves as an ideal distal nerve donor for reconstructive strategies of the hand. This transfer is also applicable to lower brachial plexus injuries. OBJECTIVE To describe the supinator to posterior interosseous nerve transfer with the goal of restoring finger extension following spinal cord or lower brachial plexus injury. METHODS Nerve branches to the supinator muscle are transferred to the posterior interosseous nerve supplying the finger extensor muscles in the forearm. RESULTS The supinator to posterior interosseous nerve transfer is effective in restoring finger extension following spinal cord or lower brachial plexus injury. CONCLUSION This procedure represents an optimal nerve transfer as the donor nerve is adjacent to the target nerve and its associated muscles. The supinator muscle is innervated by the C5-6 nerve roots and is often available in cases of cervical SCI and injuries of the lower brachial plexus. Additionally, supination function is retained by supination action of the biceps muscle.

Transfer of the supinator muscle to the extensor pollicis brevis for thumb extension reconstruction in C7-T1 brachial plexus palsy

2009 ◽  
Vol 35 (1) ◽  
pp. 29-31 ◽  
Author(s):  
J. A. Bertelli ◽  
M. F. Ghizoni ◽  
C. P. Tacca
Keyword(s):  
Brachial Plexus ◽  
Motor Nerve ◽  
Flexor Digitorum Profundus ◽  
Brachial Plexus Palsy ◽  
Extensor Pollicis Brevis ◽  
Finger Flexion ◽  
Supinator Muscle ◽  
Brachialis Muscle ◽  
Finger Motion ◽  
Flexor Digitorum

With C7-T1 brachial plexus injuries, finger motion is absent while shoulder, elbow and wrist function are largely preserved. Previously, we have reconstructed finger flexion by transferring the brachialis muscle to the flexor digitorum profundus and flexor pollicis longus; and we have restored extension of thumb and finger by transferring the motor nerve to the supinator to the posterior interosseous nerve, which is only feasible in fresh injuries. We describe the transfer of the supinator muscle to the extensor pollicis brevis to reanimate thumb extension in patients with long standing C7-T1 brachial plexus palsy.

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

2017 ◽  
Vol 43 (3) ◽  
pp. 269-274 ◽  
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

Multiple nerve and tendon transfers: a new strategy for restoring hand function in a patient with C7–T1 brachial plexus avulsions

2017 ◽  
Vol 127 (4) ◽  
pp. 837-842 ◽  
Author(s):  
Bin Xu ◽  
Zhen Dong ◽  
Cheng-Gang Zhang ◽  
Yu-Dong Gu
Keyword(s):  
Brachial Plexus ◽  
Grip Strength ◽  
Hand Function ◽  
Motor Branch ◽  
Pronator Teres ◽  
Nerve Transfers ◽  
Finger Flexion ◽  
New Strategy ◽  
Flexor Digitorum ◽  
Flexion Strength

C7–T1 brachial plexus palsies result in a loss of finger motion and hand function. The authors have observed that finger flexion motion can be recovered after a brachialis motor branch transfer. However, finger flexion strength after this procedure merely corresponds to Medical Research Council Grades M2–M3, lowering the grip strength and practical value of the reconstructed hand. Therefore, they used 2 donor nerves and accomplished double nerve transfers for stronger finger flexion. In a patient with a C7–T1 brachial plexus injury, they transferred the pronator teres branch to the anterior interosseous nerve and the brachialis motor branch to the flexor digitorum superficialis branch for reinnervation of full finger flexors. Additionally, the supinator motor branch was transferred for finger extension, and the brachioradialis muscle was used for thumb opposition recovery. Through this new strategy, the patient could successfully accomplish grasping and pinching motions. Moreover, compared with previous cases, the patient in the present case achieved stronger finger flexion and grip strength, suggesting practical improvements to the reconstructed hand.

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 Investigation Into the Optimal Number of Intercostal Nerve Transfers for Musculocutaneous Nerve Reinnervation: A Systematic Review

Hand ◽  
2017 ◽  
Vol 13 (6) ◽  
pp. 621-626 ◽  
Author(s):  
Hyuma A. Leland ◽  
Beina Azadgoli ◽  
Daniel J. Gould ◽  
Mitchel Seruya
Keyword(s):  
Systematic Review ◽  
Brachial Plexus ◽  
Donor Site ◽  
Elbow Flexion ◽  
Donor Site Morbidity ◽  
Intercostal Nerve ◽  
Optimal Number ◽  
Musculocutaneous Nerve ◽  
Nerve Transfers ◽  
Meta Analyses

Background: The purpose of this study was to systematically review outcomes following intercostal nerve (ICN) transfer for restoration of elbow flexion, with a focus on identifying the optimal number of nerve transfers. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify studies describing ICN transfers to the musculocutaneous nerve (MCN) for traumatic brachial plexus injuries in patients 16 years or older. Demographics were recorded, including age, time to operation, and level of brachial plexus injury. Muscle strength was scored based upon the British Medical Research Council scale. Results: Twelve studies met inclusion criteria for a total of 196 patients. Either 2 (n = 113), 3 (n = 69), or 4 (n = 11) ICNs were transferred to the MCN in each patient. The groups were similar with regard to patient demographics. Elbow flexion ≥M3 was achieved in 71.3% (95% confidence interval [CI], 61.1%-79.7%) of patients with 2 ICNs, 67.7% (95% CI, 55.3%-78.0%) of patients with 3 ICNs, and 77.0% (95% CI, 44.9%-93.2%) of patients with 4 ICNs ( P = .79). Elbow flexion ≥M4 was achieved in 51.1% (95% CI, 37.4%-64.6%) of patients with 2 ICNs, 42.1% (95% CI, 29.5%-55.9%) of patients with 3 ICNs, and 48.4% (95% CI, 19.2%-78.8%) of patients with 4 ICNs ( P = .66). Conclusions: Previous reports have described 2.5 times increased morbidity with each additional ICN harvest. Based on the equivalent strength of elbow flexion irrespective of the number of nerves transferred, 2 ICNs are recommended to the MCN to avoid further donor-site morbidity.

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

Hand ◽  
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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