Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries

Object In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve. Methods The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG). The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient. Conclusions The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.

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Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries

Journal of Neurosurgery ◽

10.3171/jns.2003.98.2.0313 ◽

2003 ◽

Vol 98 (2) ◽

pp. 313-318 ◽

Cited By ~ 124

Author(s):

Thomas H. Tung ◽

Christine B. Novak ◽

Susan E. Mackinnon

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Content Type ◽

Nerve Transfers ◽

Nerve Fascicle ◽

The Mean ◽

Flexion Strength ◽

Fine Print

Object. In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve. Methods. The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG). The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+ in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient. Conclusions. The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.

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Minimum Ten-Year Outcomes of Partial Ulnar Nerve Transfer for Restoration of Elbow Flexion in Patients with Upper Brachial Plexus Injury

The Journal of Hand Surgery (Asian-Pacific Volume) ◽

10.1142/s2424835519500358 ◽

2019 ◽

Vol 24 (03) ◽

pp. 283-288

Author(s):

Yusuke Nagano ◽

Daisuke Kawamura ◽

Alaa Terkawi ◽

Atsushi Urita ◽

Yuichiro Matsui ◽

...

Keyword(s):

Muscle Strength ◽

Brachial Plexus ◽

Ulnar Nerve ◽

Functional Outcomes ◽

Brachial Plexus Injury ◽

Nerve Transfer ◽

Elbow Flexion ◽

The Mean ◽

Flexion Strength

Background: Partial ulnar nerve transfer to the biceps motor branch of the musculocutaneous nerve (Oberlin’s transfer) is a successful approach to restore elbow flexion in patients with upper brachial plexus injury (BPI). However, there is no report on more than 10 years subjective and objective outcomes. The purpose of this study was to clarify the long-term outcomes of Oberlin’s transfer based on the objective evaluation of elbow flexion strength and subjective functional evaluation of patients. Methods: Six patients with BPI who underwent Oberlin’s transfer were reviewed retrospectively by their medical records. The mean age at surgery was 29.5 years, and the mean follow-up duration was 13 years. The objective functional outcomes were evaluated by biceps muscle strength using the Medical Research Council (MRC) grade at preoperative, postoperative, and final follow-up. The patient-derived subjective functional outcomes were evaluated using the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire at final follow-up. Results: All patients had MRC grade 0 (M0) or 1 (M1) elbow flexion strength before operation. Four patients gained M4 postoperatively and maintained or increased muscle strength at the final follow-up. One patient gained M3 postoperatively and at the final follow-up. Although one patient achieved M4 postoperatively, the strength was reduced to M2 due to additional disorder. The mean score of QuickDASH was 36.5 (range, 7–71). Patients were divided into two groups; three patients had lower scores and the other three patients had higher scores of QuickDASH. Conclusions: Oberlin’s transfer is effective in the restoration of elbow flexion and can maintain the strength for more than 10 years. Patients with upper BPI with restored elbow flexion strength and no complicated nerve disorders have over ten-year subjective satisfaction.

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Elbow flexion strength and contractile activity after partial ulnar nerve or intercostal nerve transfers for brachial plexus injuries

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193420922184 ◽

2020 ◽

Vol 45 (8) ◽

pp. 818-826

Author(s):

Dawn Sinn Yii Chia ◽

Kazuteru Doi ◽

Yasunori Hattori ◽

Sotetsu Sakamoto

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Muscle Power ◽

Contractile Activity ◽

Nerve Transfer ◽

Elbow Flexion ◽

Intercostal Nerve ◽

Nerve Transfers ◽

Forearm Muscles ◽

Flexion Strength

We compared the outcomes of 23 partial ulnar nerve and 15 intercostal nerve transfers for elbow flexion reconstruction in patients with C56 or C567 brachial plexus injuries using manual muscle power, dynamometric measurements of elbow flexion strength and electromyography. The range of elbow flexion and muscle strength recovery to Grade 3 or 4 were comparable between the two groups. The patients with C567 injuries had significantly stronger eccentric contraction after the partial ulnar nerve transfer than after the intercostal nerve transfer ( p < 0.05). Electromyography of individual muscles demonstrated that the patients with partial ulnar nerve transfers were unable to voluntarily isolate biceps contraction and recruited forearm flexors and extensors. The patients after partial ulnar nerve transfer had significantly more activity of the forearm muscles during concentric elbow flexion than after intercostal nerve transfers ( p < 0.05). We conclude that partial ulnar nerve transfers were superior to intercostal nerve transfers when assessed quantitatively with the dynamometer to evaluate elbow flexion, although simultaneous recruitment of forearm muscles may have contributed to the increased elbow flexion strength in the patients with the partial ulnar nerve transfer. Level of evidence: III

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Reinnervation of the biceps in C5–7 brachial plexus avulsion injuries: results after distal bypass surgery

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.7 ◽

2004 ◽

Vol 16 (5) ◽

pp. 1-4 ◽

Cited By ~ 21

Author(s):

Stefano Ferraresi ◽

Debora Garozzo ◽

Paolo Buffatti

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Hand Function ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Biceps Muscle ◽

Nerve Transfers ◽

Significant Difference ◽

Normal Hand ◽

Nerve Dysfunction

Object The authors report various techniques, and their results, after performing median and ulnar nerve transfers to reanimate the biceps muscle in C5–7 avulsion-related brachial plexus injuries (BPIs). Methods Forty-three adult patients with BPIs of the upper-middle plexus underwent reinnervation of the biceps muscle; neurotization of the musculocutaneous nerve was performed using fascicles from the ulnar nerve (39 cases) and the median nerve (four cases). The different techniques included sectioning, rerouting, and direct suturing of the entire musculocutaneous nerve (35 cases); direct reinnervation of the motor branches of the musculocutaneous nerve (three cases); and reinnervation using small grafts to the motor fascicles that enter the biceps muscle (five cases). Elbow flexion recovery ranged from M2 to M4+, according to the patient's age and the level of integrity of the hand. No surgery-related failure occurred. No significant difference in outcome was related to any of the technical variants. In patients younger than age 45 years and exhibiting a normal hand function a score of M4 or better was always achieved. On average, reinnervation occurred 6 months after surgery. There was no clinical evidence of donor nerve dysfunction. Conclusions When accurate selection criteria are met, the results after this type of neurotization have proved excellent.

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The Double Fascicular Nerve Transfer for Restoration of Elbow Flexion

Operative Neurosurgery ◽

10.1227/neu.0b013e31820958e8 ◽

2011 ◽

Vol 68 (suppl_1) ◽

pp. ons64-ons67 ◽

Cited By ~ 5

Author(s):

Charles P Toussaint ◽

Eric L Zager

Keyword(s):

Brachial Plexus ◽

Nerve Repair ◽

Nerve Transfer ◽

Elbow Flexion ◽

Musculocutaneous Nerve ◽

Shoulder Abduction ◽

Biceps Muscle ◽

Shoulder Stabilization ◽

Brachialis Muscle ◽

Nerve Fascicle

Abstract BACKGROUND: Injuries to the upper trunk of the brachial plexus are debilitating, affecting primarily shoulder abduction and elbow flexion. Treatment is aimed at restoring shoulder stabilization, shoulder abduction, and elbow flexion and may be accomplished by nerve grafting, nerve transfer, or functional muscular transfer. OBJECTIVE: To describe the double fascicular nerve transfer with the goal of restoring elbow flexion. METHODS: The double fascicular nerve transfer involves transferring an ulnar nerve fascicle to the musculocutaneous nerve innervating the biceps muscle and a median nerve fascicle transfer to a branch of musculocutaneous nerve supplying the brachialis muscle. RESULTS: The double fascicular nerve transfer is effective in restoring elbow flexion after severe upper-trunk brachial plexus injuries. CONCLUSION: Advantages of this procedure are that the nerve repair is done very close to the target muscle for reinnervation, so time to reinnervation is minimized, and the surgery takes place distal to the site of injury in nontraumatized tissue.

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Re: Chia DSY et al. Elbow flexion strength and contractile activity after partial ulnar nerve or intercostal nerve transfers for brachial plexus injuries. J Hand Surg Eur. 2020. DOI: 10.1177/1753193420922184

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193420940191 ◽

2020 ◽

Vol 45 (9) ◽

pp. 998-999

Author(s):

Tim Hems

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Contractile Activity ◽

Elbow Flexion ◽

Intercostal Nerve ◽

Nerve Transfers ◽

Flexion Strength

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

Hand ◽

10.1177/1558944717744280 ◽

2017 ◽

Vol 13 (6) ◽

pp. 621-626 ◽

Cited By ~ 2

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.

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Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

Journal of Neurosurgery ◽

10.3171/jns.2004.101.5.0770 ◽

2004 ◽

Vol 101 (5) ◽

pp. 770-778 ◽

Cited By ~ 38

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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