Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons

2004 ◽  
Vol 101 (3) ◽  
pp. 365-376 ◽  
Author(s):  
Allan J. Belzberg ◽  
Michael J. Dorsi ◽  
Phillip B. Storm ◽  
John L. Moriarity
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Surgical Intervention ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Medical Community ◽  
Shoulder Abduction ◽  
Content Type ◽  
Fine Print

Object. Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering the limb a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons as to the management of BPIs. Methods. The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians and 49 (39%) participated in the study. The respondents represent 22 different countries and multiple surgical subspecialties. They performed a mean of 33 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, treatment of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal or proximal coaptation during nerve transfer. Conclusions. Experienced peripheral nerve surgeons disagree in important ways as to the management of BPI. The decisions made by the various treating physicians underscore the many areas of disagreement regarding the treatment of BPI, including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, the treatment of neuroma-in-continuity, the choice of nerve transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons

2004 ◽  
Vol 16 (5) ◽  
pp. 1-11 ◽  
Author(s):  
Allan J. Belzberg ◽  
Michael J. Dorsi ◽  
Phillip B. Storm ◽  
John L. Moriarity
Keyword(s):  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Surgical Intervention ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Medical Community ◽  
Shoulder Abduction ◽  
Nerve Transfers ◽  
The Many

Background Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering it a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. Object The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons regarding the management of BPIs. Methods The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians of whom 49 (39%) participated in the study. The respondents represented 22 countries and multiple surgical subspecialties. They performed a mean of 34 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal compared with proximal coaptation during nerve transfer. Conclusions Experienced peripheral nerve surgeons disagreed in important respects as to the management of BPI. The decisions made by the various treating physicians underscored the many areas of disagreement regarding the treatment of BPI including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, choice of nerve transfers to achieve elbow flexion and shoulder abduction, use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

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

Neurosurgery ◽  
2012 ◽  
Vol 71 (2) ◽  
pp. 417-429 ◽  
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.

Brachial plexus repair by peripheral nerve grafts directly into the spinal cord in rats

1994 ◽  
Vol 81 (1) ◽  
pp. 107-114 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Jean Claude Mira
Keyword(s):  
Spinal Cord ◽  
Peripheral Nerve ◽  
Brachial Plexus ◽  
Elbow Flexion ◽  
Double Labeling ◽  
Content Type ◽  
Nerve Grafts ◽  
Brachial Plexus Repair ◽  
Peripheral Nerve Grafts ◽  
Fine Print

✓ Over the years, peripheral nerve grafts, a favorable environment for the support of axonal elongation, have attracted interest as a possible means of promoting spinal cord repair. In the experiments described here, rats underwent an avulsion injury of the brachial plexus, and the musculocutaneous nerve was repaired by direct insertion of peripheral nerve grafts into the spinal cord. After varying postoperative periods, the rats were submitted to a series of behavioral tests to evaluate forelimb and hindlimb function. They also underwent retrograde double-labeling studies. Nerve grafts were harvested and processed for electronic microscopy. The biceps muscle was removed and weighed and its histology studied. After surgery, central axons effectively regenerated about 65 mm along the peripheral nerve grafts, restoring normal active elbow flexion. Forelimb movements were well coordinated in both voluntary and automatic activities. Clinical investigations showed that there were no side effects in the ipsilateral forepaw, contralateral forelimb, or either hindlimb. Regenerating axons stemmed from original motoneurons, foreign motoneurons, and even antagonist motoneurons, but this did not impair function. Ganglionic neurons from adjacent roots also sent processes to the peripheral nerve grafts.

The Double Fascicular Nerve Transfer for Restoration of Elbow Flexion

2011 ◽  
Vol 68 (suppl_1) ◽  
pp. ons64-ons67 ◽  
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.

Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery

1998 ◽  
Vol 88 (2) ◽  
pp. 266-271 ◽  
Author(s):  
Martijn J. A. Malessy ◽  
Ralph T. W. M. Thomeer
Keyword(s):  
Brachial Plexus ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Musculocutaneous Nerve ◽  
Accessory Nerve ◽  
Reconstructive Procedure ◽  
Content Type ◽  
Intercostal Nerves ◽  
Brachial Plexus Surgery ◽  
Fine Print

Object. Direct coaptation of intercostal nerves (ICNs) to the musculocutaneous (MC) nerve was performed to restore elbow flexion in 25 patients with brachial plexus root avulsions. Methods. Seventy-five ICNs were transected as close as possible to the sternum to obtain sufficient length and then tunneled to the axilla and coapted to the MC nerve. Direct coaptation was achieved in 95% of ICNs, and functional elbow flexion was regained in 64% of the patients. The results were compared with several reported transfer techniques in which either an ICN or other donor nerves were used. Conclusions. Direct coaptation was equally effective and more straightforward than transfers involving interposition of grafts. The use of alternative donors such as the accessory nerve carries inherent disadvantages compared with the use of ICNs, and the results are not substantially better. Direct ICN—MC nerve transfer is a valuable reconstructive procedure.

Transfer of a Motor Fascicle From the Ulnar Nerve to the Branch of the Radial Nerve Destined to the Long Head of the Triceps for Restoration of Elbow Extension in Brachial Plexus Surgery

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. E516-E520 ◽  
Author(s):  
Leandro Pretto Flores
Keyword(s):  
Computed Tomography ◽  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Radial Nerve ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Elbow Extension ◽  
Long Head ◽  
Brachial Plexus Surgery

Abstract BACKGROUND AND IMPORTANCE: Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. CLINICAL PRESENTATION: Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. CONCLUSION: The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

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.

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

2015 ◽  
Vol 122 (1) ◽  
pp. 195-201 ◽  
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.

Effects of human amniotic fluid on peripheral nerve scarring and regeneration in rats

2003 ◽  
Vol 98 (2) ◽  
pp. 371-377 ◽  
Author(s):  
Güzin Yeşim Özgenel ◽  
Gülaydan Filiz
Keyword(s):  
Peripheral Nerve ◽  
Amniotic Fluid ◽  
Nerve Regeneration ◽  
Nerve Repair ◽  
Peripheral Nerve Regeneration ◽  
Control Group ◽  
Human Amniotic Fluid ◽  
Content Type ◽  
Repair Site ◽  
Fine Print

Object. Peripheral nerve repair surgery is still replete with challenges. Despite technical improvements in microsurgery, classic methods of nerve repair have failed to provide satisfactory results. The purpose of this study was to investigate the effects of amniotic fluid from humans on peripheral nerve scarring and regeneration in rats. Methods. Forty adult Sprague—Dawley rats were used in this study. After the right sciatic nerve in each rat was transected and repaired using an epineural suture procedure, the nerves were divided into two groups according to the solution applied around the repair site: experimental group, 0.3 ml human amniotic fluid (HAF); and control group, 0.3 ml saline. Macroscopic and histological evaluations of peripheral nerve scarring were performed 4 weeks postsurgery. Nerves treated with HAF demonstrated a significant reduction in the amount of scar tissue surrounding the repair site (p < 0.05). No evidence of a reaction against HAF was noted. Functional nerve regeneration was measured once every 2 weeks by using a sciatic function index until 12 weeks postsurgery. Functional recovery in nerves treated with amniotic fluid occurred significantly faster than that in nerves treated with saline (p < 0.05). Peripheral nerve regeneration was evaluated histomorphologically at 12 weeks postsurgery. Nerves treated with amniotic fluid showed significant improvement with respect to the indices of fiber maturation (p < 0.05). Conclusions. Preliminary data show that HAF enhances peripheral nerve regeneration. The preventive effect of HAF on epineural scarring and the rich content of neurotrophic and neurite-promoting factors possibly contribute to this result.

scholarly journals Pronator Quadratus to Extensor Carpi Radialis Brevis Nerve Transfer in C5–C7 or C5–C8 Brachial Plexus Injuries for Independent Wrist Extension

2020 ◽  
Vol 53 (01) ◽  
pp. 036-041
Author(s):  
Anil Bhatia ◽  
Mahmoud Salama
Keyword(s):  
Brachial Plexus ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Wrist Extension ◽  
Pronator Quadratus ◽  
Motor Branch ◽  
Nerve Surgery ◽  
Extensor Carpi Radialis

Abstract Background Patients with lesions affecting C7 and C8 roots (in addition to C56) demonstrate loss of independent wrist dorsiflexion in addition to loss of shoulder abduction and elbow flexion. Traditionally, this deficit has been addressed using tendon transfers after useful function at the shoulder and elbow has been restored by primary nerve surgery. Confidence with nerve transfer techniques has prompted attempts to replace this method by incorporating procedures for wrist dorsiflexion in the primary operation itself. Aim The objective of this study was to report the results of pronator quadratus motor branch transfers to the extensor carpi radialis brevis motor branch to reconstruct wrist extension in C5–C8 root lesions of the brachial plexus. Patients and Methods Twenty-three patients, average age 30 years, with C5–8 root injuries underwent operations an average of 4.7 months after their accident. Extrinsic extension of the fingers and thumb was weak or absent in two cases while the remaining 18 patients could open their hand actively. The patients lacked independent wrist extension when they were examined with the fingers flexed as the compensatory action of the extrinsic finger extensors was removed. The average follow-up was 21 months postoperative with the minimal follow-up period was at least 12 months. Results Successful reinnervations of the extensor carpi radialis brevis (ECRB) were demonstrated in all patients. In 17 patients, wrist extension scored M4, and in 3 patients it scored M3. Conclusions The pronator quadratus (PQ) to ECRB nerve transfer in C5–C7 or C5–C8 brachial plexus injuries for independent wrist extension reconstruction gives consistently good results with minimal donor morbidity.

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