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Cid-Rodríguez FX, Armas-Salazar A, González-Morales HF, Acuña-Anaya FJ, Ciprés-Aguilar JE, Juárez-Villa PM, Cruz-Rico CL, Abarca-Rojano E, Carrillo-Ruiz JD. Clinical assessment in brachial plexus injury surgery: systematic review and proposal for integrated evaluation among different medical departments. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2025; 35:164. [PMID: 40272565 DOI: 10.1007/s00590-025-04255-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2024] [Accepted: 03/09/2025] [Indexed: 04/25/2025]
Abstract
BACKGROUND Brachial plexus injury (BPI) surgery involves diversity in surgical departments including plastic surgery, hand surgery, orthopedic surgery, and neurosurgery. There is a clear scarcity in terms of unified guidelines for outcome publications due to the absence of collaboration or consensus development between departments. This study aims to identify relevant clinical parameters and their standardized presentation to address this gap. METHODS A systematic review was carried out to identify the clinical outcomes and methodological characteristics of the studies published regarding BPI surgery according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Advanced search in PubMed was performed using the MeSH terms "Brachial Plexus Injury" (Major topic) AND "Surgery" (Subheading), obtaining a total of 2382 articles. Statistical analysis was performed, and the study was registered with the PROSPERO ID: CDR42022353785. RESULTS A total of 136 articles were included to the systematic review, and 11,949 patients were evaluated in different clinical outcomes according to the preferences of the authors. Traumatic events around the world are the most common cause of injury. The clinical components most reported were: British Medical Research Council in motor at 82.3%, visual analog scale in pain was 21.3%, sensitive components at 26.4%, and quality of life in 16.1% of the cases. CONCLUSIONS The lack of standardized clinical trials highlights the need to increase the level of evidence with the aim to identify clinical evaluations among all the diverse departments to provide optimal care for BPI treatment.
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Affiliation(s)
- Fátima Ximena Cid-Rodríguez
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
- Postgraduate Department, School of Higher Education in Medicine, National Polytechnic Institute, Mexico City, Mexico
| | - Armando Armas-Salazar
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
- Postgraduate Department, School of Higher Education in Medicine, National Polytechnic Institute, Mexico City, Mexico
| | - Hannia Fernanda González-Morales
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
- Postgraduate Department, School of Higher Education in Medicine, National Polytechnic Institute, Mexico City, Mexico
| | - Fernando Joaquin Acuña-Anaya
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
- Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Juan Eduardo Ciprés-Aguilar
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
- Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Pedro Manuel Juárez-Villa
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
- Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Christian Leonardo Cruz-Rico
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico
- Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Edgar Abarca-Rojano
- Postgraduate Department, School of Higher Education in Medicine, National Polytechnic Institute, Mexico City, Mexico
| | - José D Carrillo-Ruiz
- Unit of Stereotactic and Functional Neurosurgery, General Hospital of Mexico, Mexico City, Mexico.
- Neuroscience Coordination Psychology Faculty, Mexico Anahuac University, Mexico City, Mexico.
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Johnson AR, Said A, Acevedo J, Taylor R, Wu K, Ray WZ, Patterson JM, Mackinnon SE. An Updated Evaluation of the Management of Nerve Gaps: Autografts, Allografts, and Nerve Transfers. Semin Neurol 2025; 45:157-175. [PMID: 39393799 DOI: 10.1055/s-0044-1791665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2024]
Abstract
Within the past decade, there have been multiple innovations in the field of nerve surgery. In this review, we highlight critical changes and innovations that have helped advance the field and present opportunities for further study. This includes the modification and clarification of the classification schema for nerve injuries which informs prognosis and treatment, and a refined understanding and application of electrodiagnostic studies to guide patient selection. We provide indications for operative intervention based on this nerve injury classification and propose strategies best contoured for varying injury presentations at differing time points. Lastly, we discuss new developments in surgical techniques and approaches based on these advancements.
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Affiliation(s)
- Anna Rose Johnson
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Abdullah Said
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jesus Acevedo
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ruby Taylor
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Kitty Wu
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Wilson Z Ray
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - J Megan Patterson
- Department of Orthopedic Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
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Guedes F, Llorian E, Henriques VM, Haikal N, Sanches GE. Outcomes of Oberlin Transfer in Elderly Patients: A Case Series. World Neurosurg 2025; 194:123510. [PMID: 39603458 DOI: 10.1016/j.wneu.2024.11.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2024] [Accepted: 11/19/2024] [Indexed: 11/29/2024]
Abstract
OBJECTIVE A case series analysis was performed of upper brachial plexus injuries (BPIs) from low-impact trauma in patients ≥60 years old to assess the effectiveness of nerve transfers, particularly the Oberlin technique, in restoring elbow flexion and to refine clinical decision making for managing traumatic BPIs in this age group. METHODS Between 2013 and 2024, 11 patients aged 60-72 with traumatic upper BPIs underwent Oberlin technique for elbow flexion; all were evaluated with consistent postsurgical criteria. RESULTS Trauma mechanisms included falls (55%), direct trauma (27%), knife wounds (9%), and stretching (9%), with no high-impact trauma cases. Injuries predominantly affected the right side (55%). Elbow flexion strength was assessed using the British Medical Research Council scale. Positive Tinel sign was present in 73% of patients, all reporting pain ranging from mild to severe. At 1 year postsurgery, 64% achieved M4 elbow flexion, 27% achieved M3, and 9% achieved M1 after 4 months. Patients >65 who received surgery within 6 months of injury showed better outcomes except for 1 case. No ulnar nerve deficits were observed. Following surgery, 36% experienced no pain, whereas 64% reported mild pain. Additionally, 64% underwent further nerve transfers to restore shoulder function (spinal accessory nerve to suprascapular nerve), and 18% underwent the Somsakprocedure for deltoid function. CONCLUSIONS Positive outcomes were achieved with the Oberlin technique in patients >60 with upper BPIs from low-energy trauma. However, delayed surgery, significant atrophy, and low testosterone levels may affect results. Evaluation of each patient's medical history is crucial before performing this procedure.
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Affiliation(s)
- Fernando Guedes
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, RJ, Brazil.
| | - Evelina Llorian
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, RJ, Brazil
| | - Vinícius M Henriques
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, RJ, Brazil
| | - Neder Haikal
- Department of Neurosurgery, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Gabriel Elias Sanches
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State, Rio de Janeiro, RJ, Brazil
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Czarnecki P, Górecki M, Romanowski L. Results of the Nerve Transfers and Secondary Procedures to Restore Shoulder and Elbow Function in Traumatic Upper Brachial Plexus Palsy. J Clin Med 2024; 13:7396. [PMID: 39685853 DOI: 10.3390/jcm13237396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 11/26/2024] [Accepted: 12/03/2024] [Indexed: 12/18/2024] Open
Abstract
Background: Damage to the upper trunk of the brachial plexus, often caused by high-energy trauma, leads to significant functional impairment of the upper limb. This injury primarily affects the C5 and C6 roots, resulting in paralysis of muscles critical for shoulder and elbow function. If spontaneous nerve regeneration does not occur within 3-6 months post-injury, surgical intervention, including nerve transfers, is recommended to restore function. Methods: This study evaluates long-term outcomes of nerve transfer surgeries performed between 2013 and 2023 on 16 adult patients with post-traumatic brachial plexus injuries. The most common cause of injury was motorcycle accidents. Nerve transfers targeted shoulder and elbow function restoration, including transfer of the accessory nerve to the suprascapular nerve, the radial nerve branch to the long or medial head of the triceps brachii to the axillary nerve, or the transfer of motor fascicles of the ulnar and median nerves (double Oberlin) to the brachialis and biceps brachii motor nerves. Results: Postoperative results showed varying degrees of functional recovery. In the shoulder, most patients achieved stabilization and partial restoration of active movement, with average flexion up to 92° and abduction up to 78°. In the elbow, full flexion with M4 strength was achieved in 64% of patients. In both the shoulder and the elbow, double nerve transfers yield better long-term outcomes than single transfers. Secondary procedures, such as tendon transfers, were required in some cases to improve limb strength. Conclusions: The study concludes that nerve transfers offer reliable outcomes in restoring upper limb function, although additional surgeries may be necessary in certain cases.
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Affiliation(s)
- Piotr Czarnecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznan University of Medical Sciences, 61-545 Poznań, Poland
| | - Michał Górecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznan University of Medical Sciences, 61-545 Poznań, Poland
| | - Leszek Romanowski
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznan University of Medical Sciences, 61-545 Poznań, Poland
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Lee EY, Pulos N, Bishop AT, Spinner RJ, Shin AY. The failed adult traumatic brachial plexus reconstruction. J Hand Surg Eur Vol 2024; 49:1298-1312. [PMID: 38373612 DOI: 10.1177/17531934241231170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Traumatic adult brachial plexus injuries typically cause immediate loss of upper limb function. Timely multidisciplinary treatment in specialized centres often results in a useful helper arm. Both the patient and the surgical team can benefit from an open discussion to set realistic expectations. Surgical reconstruction is customized for each patient, considering their injury factors and functional objectives. Optimizing pain control, adherence to procedure indications and using meticulous surgical techniques help minimize the risk of failing to meet the patient's goals. The need for potential alternative treatment(s) if the desired result is not achieved should be detailed before the initial reconstruction. This review discusses late treatment options, including tendon transfers, joint fusions, free functioning muscle transfers and prosthetics, for managing the failed primary reconstruction of the traumatic adult brachial plexus.
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Affiliation(s)
- Ellen Y Lee
- Department of Hand and Reconstructive Microsurgery, National University Health System, Singapore
- Department of Orthopaedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nicholas Pulos
- Department of Orthopaedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Allen T Bishop
- Department of Orthopaedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Alexander Y Shin
- Department of Orthopaedic Surgery, Division of Hand and Microvascular Surgery, Mayo Clinic, Rochester, MN, USA
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Suroto H, Wardana GR, Sugianto JA, Aprilya D, Samijo S. Time to surgery and myo-d expression in biceps muscle of adult brachial plexus injury: a preliminary study. BMC Res Notes 2023; 16:51. [PMID: 37055794 PMCID: PMC10103435 DOI: 10.1186/s13104-023-06317-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 03/27/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Brachial Plexus Injury (BPI) is one of the peripheral nerve injuries which causes severe functional impairment and disability. Without prompt treatment, prolonged denervation will cause severe muscle atrophy. MyoD, which is expressed by satellite cells, is one of the parameters that relate to the regeneration process in post-injury muscle and it is presumed to determine the clinical outcome following neurotization procedure. This study aims to understand the correlation between time to surgery (TTS) and MyoD expression in satellite cells in the biceps muscle of adult brachial plexus injury patients. METHODS Analytic observational study with a cross-sectional design was conducted at Dr. Soetomo General Hospital. All patients with BPI who underwent surgery between May 2013 and December 2015 were included. Muscle biopsy was taken and stained using immunohistochemistry for MyoD expression. Pearson correlation test was used to assess the correlation between MyoD expression with TTS and with age. RESULTS Twenty-two biceps muscle samples were examined. Most patients are males (81.8%) with an average age of 25.5 years. MyoD expression was found to be highest at TTS of 4 months and then dropped significantly (and plateau) from 9 to 36 months. MyoD expression is significantly correlated with TTS (r=-0.895; p = 0.00) but not with age (r=-0.294; p = 0.184). CONCLUSION Our study found, from the cellular point of view, that treatment of BPI needs to be done as early as possible before the regenerative potential - as indicated by MyoD expression - declined.
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Affiliation(s)
- Heri Suroto
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia.
- Cell and Tissue Bank-Regenerative Medicine, Faculty of Medicine, Dr Soetomo General Academic Hospital, Universitas Airlangga, Surabaya, 60132, Indonesia.
| | - Gestana Retaha Wardana
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia
| | - Julius Albert Sugianto
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia
| | - Dina Aprilya
- Orthopedic and Traumatology Department, Siloam Agora Hospital, Jakarta, Indonesia
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Sharma R, Gaba S, Modi M. Age correlation in upper brachial plexus injury patients undergoing nerve transfer surgeries. BRAIN & SPINE 2022; 2:101695. [PMID: 36506296 PMCID: PMC9729817 DOI: 10.1016/j.bas.2022.101695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/11/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
•A patient's age can be a critical factor influencing the outcome following upper brachial plexus injury (BPI) reconstruction.•The favorable factor being younger patients with short denervation period.•In older patients early and more aggressive management for an optimal outcome.•This study supports the various correlation of age with the outcomes of upper brachial plexus reconstruction surgery.
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Affiliation(s)
- Raman Sharma
- Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Gaba
- Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Corresponding author. Department of Plastic surgery, Postgraduate Institute of Medical Education and Research Chandigarh, 160012, India.
| | - Manish Modi
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Lu F, Zhang G, Zhu Y, Liu Z. (-)-Epigallocatechin Gallate Attenuates Spinal Motoneuron Death Induced by Brachial Plexus Root Avulsion in Rats. Curr Med Chem 2022; 29:5139-5154. [PMID: 35579165 DOI: 10.2174/0929867329666220509204151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 11/22/2022]
Abstract
Background:
Recent studies have indicated that epigallocatechin gallate (EGCG) benefits a variety of neurological insults. This study was performed to investigate the neuroprotective effect of EGCG after brachial plexus root avulsion in SD rats.
Methods:
One hundred twenty SD rats were randomized into the following three groups: an EGCG group, an Avulsion group, and a Sham group. There were 40 rats in each group. EGCG (100 mg/kg, i.p.) or normal saline was administered to rats immediately following the injuries. The treatment was continued from day 1 to day 7, and the animals were sacrificed on days 3, 7, 14 and 28 post-surgery for the harvesting of spinal cord samples for Nissl staining, immunohistochemistry (caspase-3, p-JNK, p-c-Jun) and western blot analysis (p-JNK, JNK, p-c-Jun, c-Jun).
Results:
EGCG treatment caused significant increases in the percentage of surviving motoneurons at days 14 and 28 (P<0.05) compared to the control animals. At days 3 and 7 after avulsion, the numbers of caspase-3-positive motoneurons in the EGCG-treated animals were significantly fewer than in the control animals (P<0.05). The numbers of p-JNK-positive motoneurons and the ratio of p-JNK/JNK were no significant differences between the Avulsion group and the EGCG-treated group after injury at any time point. The numbers of p-c-Jun-positive motoneurons and the ratio of p-c-Jun/c-Jun were significantly lower in EGCG-treated group compared with the Avulsion group at 3d and 7d after injury (p<0.05).
Conclusions:
Our results indicated that motoneurons were protected by EGCG against the cell death induced by brachial plexus root avulsion, and this effect was correlated with inhibiting c-Jun phosphorylation.
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Affiliation(s)
- Fatai Lu
- Department of Orthopedics, The Fourth Affiliated Hospital of China Medical University, No.4 Chongshan Dong Street, Huanggu District, Shenyang 110032, Liaoning Province, PR China
| | - Guodong Zhang
- Department of Orthopedics, The Fourth Affiliated Hospital of China Medical University, No.4 Chongshan Dong Street, Huanggu District, Shenyang 110032, Liaoning Province, PR China
| | - Yingkang Zhu
- Department of Orthopedics, The Fourth Affiliated Hospital of China Medical University, No.4 Chongshan Dong Street, Huanggu District, Shenyang 110032, Liaoning Province, PR China
| | - Zunpeng Liu
- Department of Orthopedics, The Fourth Affiliated Hospital of China Medical University, No.4 Chongshan Dong Street, Huanggu District, Shenyang 110032, Liaoning Province, PR China
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Singh VK, Haq A, Tiwari M, Saxena AK. Approach to management of nerve gaps in peripheral nerve injuries. Injury 2022; 53:1308-1318. [PMID: 35105440 DOI: 10.1016/j.injury.2022.01.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 02/02/2023]
Abstract
Peripheral nerve injuries (PNI) are a major clinical problem. In general, PNI results from motor vehicle accidents, lacerations with sharp objects, penetrating trauma (gunshot wounds) and stretching or crushing trauma and fractures. They can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Currently, the standard surgical technique for complete nerve transection is end-to-end neurorrhaphy. Unfortunately, there is segmental loss of the nerve trunk in some cases where nerve mobilization may permit end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. But in light of limited availability and concerned donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers and end-to-side neurorrhaphy. This review intends to present an overview of the literature on the applications of these techniques in repair of peripheral nerve injuries. This article also focuses on preoperative assessment, surgical timing, available options and future perspectives.
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Affiliation(s)
- Veena K Singh
- Department of Burns & Plastic surgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | - Ansarul Haq
- Department of Burns & Plastic surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Meenakshi Tiwari
- Department of Pathology/Lab Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Ajit K Saxena
- Department of Pathology/Lab Medicine, All India Institute of Medical Sciences, Patna, Bihar, India
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Kim RB, Bounajem M, Hamrick F, Mahan MA. Optimal Donor Nerve to Restore Elbow Flexion After Traumatic Brachial Plexus Injury: A Systematic Review and Meta-Analysis. Neurosurgery 2022; 90:39-50. [PMID: 34982869 DOI: 10.1227/neu.0000000000001737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traumatic brachial plexus injuries (BPIs) often lead to devastating upper extremity deficits. Treatment frequently prioritizes restoring elbow flexion through transfer of various donor nerves; however, no consensus identifies optimal donor nerve sources. OBJECTIVE To complete a meta-analysis to assess donor nerves for restoring elbow flexion after partial and total BPI (TBPI). METHODS Original English language articles on nerve transfers to restore elbow flexion after BPI were included. Using a random-effects model, we calculated pooled, weighted effect size of the patients achieving a composite motor score of ≥M3, with subgroup analyses for patients achieving M4 strength and with TBPI. Meta-regression was performed to assess comparative efficacy of each donor nerve for these outcomes. RESULTS Comparison of the overall effect size of the 61 included articles demonstrated that intercostal nerves and phrenic nerves were statistically superior to contralateral C7 (cC7; P = .025, <.001, respectively) in achieving ≥M3 strength. After stratification by TBPI, the phrenic nerve was still superior to cC7 in achieving ≥M3 strength (P = .009). There were no statistical differences among ulnar, double fascicle, or medial pectoral nerves in achieving ≥M3 strength. Regarding M4 strength, the phrenic nerve was superior to cC7 (P = .01) in patients with TBPI and the ulnar nerve was superior to the medial pectoral nerve (P = .036) for partial BPI. CONCLUSION Neurotization of partial BPI or TBPI through the intercostal nerve or phrenic nerve may result in functional advantage over cC7. In patients with upper trunk injuries, neurotization using ulnar, median, or double fascicle nerve transfers has similarly excellent functional recovery.
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Affiliation(s)
- Robert B Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Forrest Hamrick
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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Estrada RG, Bacca J, Socolovsky M. A novel dual nerve transfer for restoration of shoulder function and sensory recovery of the hand, in patients with C567 traumatic root avulsion of the brachial plexus. Clin Neurol Neurosurg 2021; 210:107005. [PMID: 34741973 DOI: 10.1016/j.clineuro.2021.107005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/16/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of our study is to determine the anatomical viability in cadavers of a novel doble nerve transfer technique for simultaneous reanimation of shoulder abduction and sensory recovery of the hand, in patients with brachial plexus injuries sustaining a C5-C6-C7 roots avulsion. These new transfers should be complemented in the clinical setting with other classic nerve transfers, i.e.: (1) a spinal accessory to suprascapular for shoulder abduction and stability, (2) ulnar nerve fascicles to the biceps branches of the musculocutaneous for elbow flexion, and (3) intercostal to triceps branches for elbow extension. METHODS The proposed surgical technique includes (1) transferring motor fascicles of the median nerve (MNF), as donors to the axillary nerve (AN), and (2) the whole medial antebrachial cutaneous nerve (MACN) to the lateral contribution (sensory) of the median nerve (LCMN), both without the use of interposed nerve grafts. These techniques were performed in eight cadaveric upper extremities. Analyzed variables were: donor and receptor nerves diameter, length and distance of donor and receptors nerves, and axonal count. RESULTS The mean distance between the MNF and its point of coaptation to the AN was 19 mm. The average length of each one of the MNF, after distal dissection, was 46.5 mm. The average diameter of each fascicle of the median nerve at its coaptation point with the axillary nerve was 0.8 mm, while the average diameter of the latter was 3.9 mm. The average distance between the MACN and its point of coaptation to the LCMN, was 16.5 mm. The average diameter of the MACN and the LCMN at their point of coaptation, were 2.7 mm and 3.5 mm, respectively. CONCLUSION These nerve transfers are anatomically viable and could be a complement for other currently used techniques that can be employed in severely injured C567 brachial plexus patients.
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Affiliation(s)
- Ricardo González Estrada
- Peripheral Nerve and Brachial Plexus Surgery Unit, Department of Neurosurgery, Clinica Bolivariana, Universidad Pontificia Bolivariana School of Medicine, Medellin, Colombia.
| | - Juliana Bacca
- Department of Pathology, University of Antioquia, Medellin, Colombia.
| | - Mariano Socolovsky
- Peripheral Nerve and Brachial Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina.
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Abstract
Brachial plexus injuries are still challenging for every surgeon taking part in treating patients with BPI. Injuries of the brachial plexus can be divided into injuries of the upper trunk, extended upper trunk, injuries of the lower trunk and swinging hand where all of the roots are involved in this type of the injury. Brachial plexus can be divided in five anatomical sections from its roots to its terminal branches: roots, trunks, division, cords and terminal branches. Brachial plexus ends up as five terminal branches, responsible for upper limb innervation, musculocutaneous, median nerve, axillary nerve, radial and ulnar nerve. According to the findings from the preoperative investigation combined with clinically found functional deficit, the type of BPI will be confirmed and that is going to determine which surgical procedure, from variety of them (neurolysis, nerve graft, neurotization, arthrodesis, tendon transfer, free muscle transfer, bionic reconstruction) is appropriate for treating the patient.
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13
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El-Gammal TA, El-Sayed A, Kotb MM, Abdel-Hamid UF, El-Gammal YT. Long-Term Outcome of Phrenic Nerve Transfer in Brachial Plexus Avulsion Injuries. Ann Plast Surg 2021; 86:188-192. [PMID: 33346562 DOI: 10.1097/sap.0000000000002611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years. PATIENTS AND METHODS Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years. RESULTS Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms. CONCLUSIONS The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.
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Affiliation(s)
- Tarek Abdalla El-Gammal
- From the Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
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Titolo P, Lavorato A, Isoardo G, Vincitorio F, Garbossa D, Battiston B. Transfer of the peroneal component of the sciatic nerve in total brachial plexus lesion: An anatomical feasibility study. Injury 2020; 51:2904-2909. [PMID: 32201119 DOI: 10.1016/j.injury.2020.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/22/2020] [Accepted: 03/07/2020] [Indexed: 02/02/2023]
Abstract
Closed brachial plexus lesions (BPLs) are generally associated with a traumatic mechanism of forced traction between the neck and the shoulder-arm complex. For brachial plexus reconstruction different techniques have been proposed with donor motor nerves like intercostal nerves, or the ipsilateral cervical plexus, the phrenic nerve, the contralateral C7 root, and many others. Despite all these surgical possibilities, the overall recovery is generally poor and not satisfactory. The principal drawback is linked to the loss of upper limb proprioception, in a way that dramatically influences even a good motor recovery, so in complete BPLs the sensory loss still represents a debilitating problem. In this anatomical feasibility study, the possibility to transfer the peroneal component of the sciatic nerve as a donor for complete BPLs has been evaluated. This technique would conceptually bring an important motor and sensory contribution to the upper limb using pure motor and sensory branches of the sciatic nerve. Performing immediate tendon transfer for foot drop palsy could significantly decrease the morbidity of the surgical procedure.
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Affiliation(s)
- Paolo Titolo
- OU Traumatology-Reconstructive Microsurgery, Department of Orthopaedics and Traumatology, CTO Hospital, Torino, Italy
| | - Andrea Lavorato
- OU Neurosurgery, Department of Neurosciences, University of Turin, Turin, Italy.
| | - Gianluca Isoardo
- Centre for Pain Treatment, Department of Anesthesiology, Resuscitation and Intensive Care, Città della Salute e della Scienza di Torino - Molinette Hospital, Italy
| | | | - Diego Garbossa
- OU Neurosurgery, Department of Neurosciences, University of Turin, Turin, Italy
| | - Bruno Battiston
- OU Traumatology-Reconstructive Microsurgery, Department of Orthopaedics and Traumatology, CTO Hospital, Torino, Italy
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15
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Functional outcome predictors after spinal accessory nerve to suprascapular nerve transfer for restoration of shoulder abduction in traumatic brachial plexus injuries in adults: the effect of time from injury to surgery. Eur J Trauma Emerg Surg 2020; 48:1217-1223. [PMID: 32980882 DOI: 10.1007/s00068-020-01501-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Shoulder abduction is crucial for daily activities, and its restoration is one of the surgical priorities. We evaluated the predictive factors of shoulder abduction functional outcome after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, with special emphasis on the effect of time from injury to the surgery, in the treatment of traumatic brachial plexus injuries. METHOD This cohort included adult patients who underwent SAN-to-SSN transfer with a preoperative Medical Research Council strength grade 0 and a follow-up of minimum 18 months. The primary outcome was shoulder abduction function (bad, < 30°; good, 30°-60°; or excellent, > 60°). Demographics, trauma characteristics, time lapse between injury and surgery, concomitant axillary nerve reconstruction, and surgery duration were registered. Ordinal logistic regression was used to identify predictors of functional outcomes. RESULTS The records of 83 patients (86.7% men, mean age 28.8 ± 9.8 years) were analysed. Mean body mass index was 24.1 ± 3.7 kg/m2, and 43.1% were overweight/obese. Motorcycle crashes were the most common trauma mechanism (88.0%). Excellent, good, and bad outcomes were achieved by 20.4%, 38.6%, and 41.0%, respectively. Older patients tended to have worse outcomes (p = 0.074), as well as left-sided lesions (p = 0.015) or those contralateral to manual dominance (p = 0.057). The longer the interval between injury and surgery the worse the outcome: excellent, 5.5 (4.3-7.1); good, 6.9 (5.9-8.7); and bad, 8.2 (5.7-10.1) months (p = 0.018). After multivariable analysis, longer time interval predicted lower odds of better outcomes (OR 0.823, 95% CI 0.699-0.970, p = 0.020; 17.7% lower odds of good or excellent outcome for each additional month). The odd of good or excellent outcomes was also associated with axillary nerve reconstruction (OR 2.767, 95% CI 1.016-7.536, p = 0.046), but not with age or lesion laterality. CONCLUSIONS Excellent or good functional outcomes for shoulder abduction were achieved by almost sixty percent of adults who underwent SAN-to-SSN transfer for reconstruction of traumatic brachial plexus injuries, associated or not with axillary nerve reconstruction strategies. Longer delays from injury to surgery predicted worse outcomes, and the best time frame seemed to be less than 6 months.
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Socolovsky M, Cardoso MDM, Lovaglio A, di Masi G, Bonilla G, de Amoreira Gepp R. Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series. Oper Neurosurg (Hagerstown) 2020; 19:249-254. [PMID: 32497215 DOI: 10.1093/ons/opaa163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/06/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The phrenic nerve has been extensively reported to be a very powerful source of transferable axons in brachial plexus injuries. The most used technique used is supraclavicular sectioning of this nerve. More recently, video-assisted thoracoscopic techniques have been reported as a good alternative, since harvesting a longer phrenic nerve avoids the need of an interposed graft. OBJECTIVE To compare grafting vs phrenic nerve transfer via thoracoscopy with respect to mean elbow strength at final follow-up. METHODS A retrospective analysis was conducted among patients who underwent phrenic nerve transfer for elbow flexion at 2 centers from 2008 to 2017. All data analysis was performed in order to determine statistical significance among the analyzed variables. RESULTS A total of 32 patients underwent supraclavicular phrenic nerve transfer, while 28 underwent phrenic nerve transfer via video-assisted thoracoscopy. Demographic characteristics were similar in both groups. A statistically significant difference in elbow flexion strength recovery was observed, favoring the supraclavicular phrenic nerve section group against the intrathoracic group (P = .036). A moderate though nonsignificant difference was observed favoring the same group in mean elbow flexion strength. Also, statistical differences included patient age (P = .01) and earlier time from trauma to surgery (P = .069). CONCLUSION Comparing supraclavicular sectioning of the nerve vs video-assisted, intrathoracic nerve sectioning to restore elbow flexion showed that the former yielded statistically better results than the latter, in terms of the percentage of patients who achieve at least level 3 MRC strength at final follow-up. Furthermore, larger scale prospective studies assessing the long-term effects of phrenic nerve transfers remain necessary.
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Affiliation(s)
- Mariano Socolovsky
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | | | - Ana Lovaglio
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gilda di Masi
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gonzalo Bonilla
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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17
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Bhatia A, Kulkarni A, Zancolli P, Martinez RR, Clifton J, El-Gammal T, Muset A. The Effect of Age and the Delay before Surgery on the Outcomes of Intercostal Nerve Transfers to the Musculocutaneous Nerve: A Retrospective Study of 232 Cases of Posttraumatic Total and Near-total Brachial Plexus Injuries. Indian J Plast Surg 2020; 53:260-265. [PMID: 32884192 PMCID: PMC7458838 DOI: 10.1055/s-0040-1716081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Introduction
Posttraumatic brachial plexus injuries are devastating, as the brain and spinal cord are disconnected from the upper limb. Restoration of elbow flexion has been widely recognized as the primary objective of nerve reconstruction. In the absence of utilizable (ruptured) root stumps in the neck, one has recourse only to nerve transfers. The direct transfer of intercostal nerves to the musculocutaneous nerve is one of the techniques that has been commonly employed over the past four decades. However, the outcomes of this procedure cited in the literature have varied considerably. The patient’s age and the delay from the accident to surgery have been known to affect the results of nerve reconstruction operations. The authors present a study of the effect of these parameters on intercostal nerve transfers.
Methods
The data of 232 patients with total and near-total brachial plexus injuries treated by the senior author between April 1995 and December 2015 was examined. Intercostal nerve transfers were used for the restoration of biceps function in each of these patients. The outcomes were tabulated, and the correlation with the age and the delay before surgery was examined.
Results
The strength of the biceps regained was better in patients younger than 30 years old and those operated upon earlier than 6 months from the accident. The differences in outcomes were found to be statistically significant (
p
= 0.001 for preoperative delay and
p
< 0.005 for the patient’s age).
Conclusion
The results give clear proof of the significant effect of the age and preoperative delay on the outcomes of intercostal nerve transfers for restoration of biceps function. These findings can serve as pointers to help the surgeon in choosing the method of nerve reconstruction in a given case.
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Affiliation(s)
- Anil Bhatia
- Departmentof Brachial Plexus, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Aditi Kulkarni
- Departmentof Brachial Plexus, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Pablo Zancolli
- Departmentof Hand Surgery, Fundacion Favaloro, Buenos Aires, Argentina
| | - Raul Rodriguez Martinez
- Department of Brachial Plexus and Hand Surgery, Clínica Mielina Plexo Braquial, Hospital Real San José, Guadalajara, Mexico
| | - Jorge Clifton
- Department of Brachial Plexus and Hand Surgery, Clínica Mielina Plexo Braquial, Hospital Real San José, Guadalajara, Mexico
| | - Tarek El-Gammal
- Departmentof Brachial Plexus, Assiut University, Assiut, Egypt
| | - Alex Muset
- Departmentof Brachial Plexus and Hand Surgery, Muset Institute, Barcelona, Spain
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Hermena S, El-Gammal T, El-Sayed A, Kotb MM. Evaluation of Triple Neurotization Technique as a Single Procedure in Adult Traumatic Brachial Plexus Injury. Cureus 2020; 12:e6660. [PMID: 32089969 PMCID: PMC7021238 DOI: 10.7759/cureus.6660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/15/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Brachial plexus injuries are common and result in significant disabilities. This study evaluated the outcome of triple neurotization as a single procedure for upper trunk brachial plexus injury. PATIENTS AND METHODS Some 25 adult consecutive patients with injured upper trunk brachial plexus who underwent microscopic reconstructive surgery using triple neurotization technique in the authors' institute were recruited in this study. Data on operative and functional outcomes were captured. Modified Narkas scale was used to evaluate the shoulder function in addition to Waikakul scale which was used to evaluate the elbow function. Data were analyzed with respect to short and long term with a median follow-up duration of two years. RESULTS Assessment of the recovered shoulder abduction was excellent in 48% (n=12), good in 24% (n=6), fair in 16% (n=4), and poor in 12% of cases (n=3). Shoulder external rotation recovery was excellent in 48% (n=12), good in 12% (n=3), fair in 12% (n=3), and poor in 28% of cases (n=7). Recovery of elbow flexion was excellent in 60% (n=15), good in 12% (n=3), fair in 12% (n=3), and poor in 16% of cases (n=4). The mean value of recovered shoulder abduction was 111.26 degrees (range: 70-150). The mean value of restored shoulder external rotation was 57.5 degrees (range: 45-70). The mean value of restored elbow flexion was 75 degrees (range: 55-120). CONCLUSION Triple neurotization technique can be effective to restore elbow flexion, shoulder abduction, and external rotation in adult patients with upper trunk brachial plexus injury.
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Affiliation(s)
- Shady Hermena
- Trauma and Orthopedics, Yeovil District Hospital, Yeovil, GBR
| | - Tarek El-Gammal
- Trauma and Orthopedics, Assiut University Hospital, Assiut, EGY
| | - Amr El-Sayed
- Trauma and Orthopedics, Assiut University Hospital, Assiut, EGY
| | - Mohamed M Kotb
- Trauma and Orthopedics, Assiut University Hospital, Assiut, EGY
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Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
| | - John J Kelly
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York.,School of Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Aakash M Patel
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York.,Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois
| | - Colin M White
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
| | - Michael R Hausman
- Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven M Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Medical Center, Brooklyn, New York
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20
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Bassilios Habre S, Bond G, Jing XL, Kostopoulos E, Wallace RD, Konofaos P. The Surgical Management of Nerve Gaps: Present and Future. Ann Plast Surg 2019; 80:252-261. [PMID: 29166306 DOI: 10.1097/sap.0000000000001252] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peripheral nerve injuries can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Nowadays, the gold standard for the treatment of nerve section is end-to-end neurorrhaphy. Unfortunately, in some cases, there is segmental loss of the nerve trunk. Nerve mobilization allows primary repair of the sectioned nerve by end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. To overcome the limited availability and the donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers, and end-to-side neurorrhaphy. The purpose of this review is to present an overview of the literature on the applications of these techniques in peripheral nerve repair. Furthermore, preoperative evaluation, timing of repair, and future perspectives are also discussed.
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Recovery of shoulder abduction in traumatic brachial plexus palsy: a systematic review and meta-analysis of nerve transfer versus nerve graft. Neurosurg Rev 2019; 43:951-956. [DOI: 10.1007/s10143-019-01100-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
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Martin E, Senders JT, DiRisio AC, Smith TR, Broekman MLD. Timing of surgery in traumatic brachial plexus injury: a systematic review. J Neurosurg 2019; 130:1333-1345. [PMID: 29999446 DOI: 10.3171/2018.1.jns172068] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/10/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Ideal timeframes for operating on traumatic stretch and blunt brachial plexus injuries remain a topic of debate. Whereas on the one hand spontaneous recovery might occur, on the other hand, long delays are believed to result in poorer functional outcomes. The goal of this review is to assess the optimal timeframe for surgical intervention for traumatic brachial plexus injuries. METHODS A systematic search was performed in January 2017 in PubMed and Embase databases according to the PRISMA guidelines. Search terms related to "brachial plexus injury" and "timing" were used. Obstetric plexus palsies were excluded. Qualitative synthesis was performed on all studies. Timing of operation and motor outcome were collected from individual patient data. Patients were categorized into 5 delay groups (0-3, 3-6, 6-9, 9-12, and > 12 months). Median delays were calculated for Medical Research Council (MRC) muscle grade ≥ 3 and ≥ 4 recoveries. RESULTS Forty-three studies were included after full-text screening. Most articles showed significantly better motor outcome with delays to surgery less than 6 months, with some studies specifying even shorter delays. Pain and quality of life scores were also significantly better with shorter delays. Nerve reconstructions performed after long time intervals, even more than 12 months, can still be useful. All papers reporting individual-level patient data described a combined total of 569 patients; 65.5% of all patients underwent operations within 6 months and 27.4% within 3 months. The highest percentage of ≥ MRC grade 3 (89.7%) was observed in the group operated on within 3 months. These percentages decreased with longer delays, with only 35.7% ≥ MRC grade 3 with delays > 12 months. A median delay of 4 months (IQR 3-6 months) was observed for a recovery of ≥ MRC grade 3, compared with a median delay of 7 months (IQR 5-11 months) for ≤ MRC grade 3 recovery. CONCLUSIONS The results of this systematic review show that in stretch and blunt injury of the brachial plexus, the optimal time to surgery is shorter than 6 months. In general, a 3-month delay appears to be appropriate because while recovery is better in those operated on earlier, this must be considered given the potential for spontaneous recovery.
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Affiliation(s)
- Enrico Martin
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joeky T Senders
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aislyn C DiRisio
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marike L D Broekman
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Outcomes of Elbow Flexion Reconstruction in Patients Older than 50 with Traumatic Brachial Plexus Injury. Plast Reconstr Surg 2019; 143:151-158. [PMID: 30325896 DOI: 10.1097/prs.0000000000005094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is controversy regarding the effectiveness of brachial plexus reconstruction for elbow function in older patients, as reported outcomes are generally poor. The purpose of this study was to evaluate elbow function outcomes in patients older than 50. METHODS Fifty-eight patients older than 50 years underwent nerve grafting, transfers, or free functioning muscle transfer to improve elbow function after traumatic brachial plexus injury. Patients were evaluated preoperatively and postoperatively for elbow flexion strength and range of motion; Disabilities of the Arm, Shoulder and Hand scores; pain; concomitant trauma; severity of trauma; and type of reconstruction. RESULTS The average age of the patients was 57.8 years, and the average follow-up was 24.0 months. The average modified British Medical Research Council elbow flexion grade improved significantly from 0.26 to 2.63. Thirty-three patients (60 percent) achieved functional flexion greater than or equal to M3 postoperatively, compared to zero patients preoperatively. There was no correlation between age and modified British Medical Research Council grade. Active elbow range of motion improved significantly postoperatively, with no effect of age on flexion motion. More patients achieved greater than or equal to M3 flexion with nerve transfers (69 percent) compared to free functioning muscle transfer (43 percent). Patients had worse outcomes with high-energy injuries. The mean Disabilities of the Arm, Shoulder and Hand score decreased from 51.5 to 49.6 postoperatively, and the average pain score decreased from 5.0 to 4.3. CONCLUSION Brachial plexus reconstruction for elbow function in patients older than 50 can yield useful flexion. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Midha R, Grochmal J. Surgery for nerve injury: current and future perspectives. J Neurosurg 2019; 130:675-685. [PMID: 30835708 DOI: 10.3171/2018.11.jns181520] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Abstract
In this review article, the authors offer their perspective on nerve surgery for nerve injury, with a focus on recent evolution of management and the current surgical management. The authors provide a brief historical perspective to lay the foundations of the modern understanding of clinical nerve injury and its evolving management, especially over the last century. The shift from evaluation of the nerve injury using macroscopic techniques of exploration and external neurolysis to microscopic interrogation, interfascicular dissection, and internal neurolysis along with the use of intraoperative electrophysiology were important advances of the past 50 years. By the late 20th century, the advent and popularization of interfascicular nerve grafting techniques heralded a major advance in nerve reconstruction and allowed good outcomes to be achieved in a large percentage of nerve injury repair cases. In the past 2 decades, there has been a paradigm shift in surgical nerve repair, wherein surgeons are not only directing the repair at the injury zone, but also are deliberately performing distal-targeted nerve transfers as a preferred alternative in an attempt to restore function. The peripheral rewiring approach allows the surgeon to convert a very proximal injury with long regeneration distances and (often) uncertain outcomes to a distal injury and repair with a greater potential of regenerative success and functional recovery. Nerve transfers, originally performed as a salvage procedure for severe brachial plexus avulsion injuries, are now routinely done for various less severe brachial plexus injuries and many other proximal nerve injuries, with reliably good to even excellent results. The outcomes from nerve transfers for select clinical nerve injury are emphasized in this review. Extension of the rewiring paradigm with nerve transfers for CNS lesions such as spinal cord injury and stroke are showing great potential and promise. Cortical reeducation is required for success, and an emerging field of rehabilitation and restorative neurosciences is evident, which couples a nerve transfer procedure to robotically controlled limbs and mind-machine interfacing. The future for peripheral nerve repair has never been more exciting.
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Affiliation(s)
- Rajiv Midha
- 1Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada; and
| | - Joey Grochmal
- 2Neurosurgery, University Medical Center, Lubbock, Texas
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Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children. Childs Nerv Syst 2019; 35:349-354. [PMID: 30610478 DOI: 10.1007/s00381-018-04036-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years. METHODS We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months. RESULTS The majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases. CONCLUSIONS There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).
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Gillis JA, Khouri JS, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Outcomes of shoulder abduction after nerve surgery in patients over 50 years following traumatic brachial plexus injury. J Plast Reconstr Aesthet Surg 2018; 72:12-19. [PMID: 30293962 DOI: 10.1016/j.bjps.2018.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 09/05/2018] [Accepted: 09/10/2018] [Indexed: 12/12/2022]
Abstract
PURPOSE There is controversy regarding the effectiveness of brachial plexus reconstruction in older patients, as outcomes are thought to be poor. The aim of this study is to determine the outcomes of shoulder abduction obtained after nerve reconstruction in patients over the age of 50 years and factors related to success. METHODS Forty patients over the age of 50 years underwent nerve surgery to improve shoulder function after a traumatic brachial plexus injury. Patients were evaluated pre- and postoperatively for shoulder abduction strength and range of motion (ROM); Disability of the Arm, Shoulder and Hand (DASH) scores; pain; age bracket; gender; body mass index (BMI); delay from injury to operation; concomitant trauma; severity of trauma; and type of reconstruction. RESULTS The average age was 58.2 years (range 50-77 years) with an average follow-up of 18.8 months. The average modified British Medical Research Council (BMRC) shoulder abduction grade improved significantly from 0.23 to 2.03 (p < 0.005). Fourteen patients achieved functional shoulder abduction of ≥ M3 postoperatively. There was no correlation between age or age range stratification and BMRC grade or those obtaining useful shoulder abduction ≥ M3. Active shoulder abduction improved significantly from 18.25° to 40.64°, with no difference on the basis of age or age stratification. There were improved modified BMRC grades with nerve transfers versus nerve grafts. Less patients achieved ≥ M3 function if surgery was delayed > 6 months. The mean DASH score decreased from 45.3 to 40.7 postoperatively, and the average pain score decreased from 3.7 to 3.0. Patients with a higher postoperative BMRC grade for shoulder abduction had improved postoperative DASH scores and VAS for pain (p = 0.011 and 0.005, respectively). CONCLUSION Brachial plexus nerve reconstruction for shoulder abduction in patients over the age of 50 years can yield useful BMRC scores and ROM, and age should not be used to exclude nerve reconstruction in these patients.
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Affiliation(s)
- Joshua A Gillis
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph S Khouri
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Robert J Spinner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Jácome DT, Alencar FHUD, Lemos MVVD, Kobig RN, Rocha JFR. Axillary nerve neurotization by a triceps motor branch: comparison between axillary and posterior arm approaches. Rev Bras Ortop 2018; 53:15-21. [PMID: 29367901 PMCID: PMC5771792 DOI: 10.1016/j.rboe.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 11/22/2016] [Indexed: 11/24/2022] Open
Abstract
Objectives This study is aimed at comparing the functional outcome of axillary nerve neurotization by a triceps motor branch through the axillary approach and posterior arm approach. Methods The study included 27 patients with post-traumatic brachial plexus injury treated with axillary nerve neurotization by a triceps motor branch for functional recovery of shoulder abduction and external rotation. The patients were retrospectively evaluated and two groups were identified, one with 13 patients undergoing axillary nerve neurotization by an axillary approach and the second with 14 patients using the posterior arm approach. Patients underwent assessment of muscle strength using the scale recommended by the British Medical Research Council, preoperatively and 18 months postoperatively, with useful function recovery considered as grade M3 or greater. Results In the axillary approach group, 76.9% of patients achieved useful abduction function recovery and 69.2% achieved useful external rotation function recovery. In the group with posterior arm approach, 71.4% of patients achieved useful abduction function recovery and 50% achieved useful external rotation function recovery. The difference between the two groups was not statistically significant (p = 1.000 for the British Medical Research Council abduction scale and p = 0.440 for external rotation). Conclusion According to the British Medical Research Council grading, axillary nerve neurotization with a triceps motor branch using axillary approach or posterior arm approach shows no statistical differences.
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Affiliation(s)
- Daniel Tôrres Jácome
- Instituto Nacional de Traumatologia e Ortopedia (Into), Rio de Janeiro, RJ, Brazil
| | | | | | - Rudolf Nunes Kobig
- Instituto Nacional de Traumatologia e Ortopedia (Into), Rio de Janeiro, RJ, Brazil
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Gao KM, Lao J, Guan WJ, Hu JJ. Is it necessary to use the entire root as a donor when transferring contralateral C 7 nerve to repair median nerve? Neural Regen Res 2018; 13:94-99. [PMID: 29451212 PMCID: PMC5840998 DOI: 10.4103/1673-5374.224376] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
If a partial contralateral C7 nerve is transferred to a recipient injured nerve, results are not satisfactory. However, if an entire contralateral C7 nerve is used to repair two nerves, both recipient nerves show good recovery. These findings seem contradictory, as the above two methods use the same donor nerve, only the cutting method of the contralateral C7 nerve is different. To verify whether this can actually result in different repair effects, we divided rats with right total brachial plexus injury into three groups. In the entire root group, the entire contralateral C7 root was transected and transferred to the median nerve of the affected limb. In the posterior division group, only the posterior division of the contralateral C7 root was transected and transferred to the median nerve. In the entire root + posterior division group, the entire contralateral C7 root was transected but only the posterior division was transferred to the median nerve. After neurectomy, the median nerve was repaired on the affected side in the three groups. At 8, 12, and 16 weeks postoperatively, electrophysiological examination showed that maximum amplitude, latency, muscle tetanic contraction force, and muscle fiber cross-sectional area of the flexor digitorum superficialis muscle were significantly better in the entire root and entire root + posterior division groups than in the posterior division group. No significant difference was found between the entire root and entire root + posterior division groups. Counts of myelinated axons in the median nerve were greater in the entire root group than in the entire root + posterior division group, which were greater than the posterior division group. We conclude that for the same recipient nerve, harvesting of the entire contralateral C7 root achieved significantly better recovery than partial harvesting, even if only part of the entire root was used for transfer. This result indicates that the entire root should be used as a donor when transferring contralateral C7 nerve.
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Affiliation(s)
- Kai-Ming Gao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Wen-Jie Guan
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jing-Jing Hu
- Nursing Department, Huashan Hospital, Fudan University, Shanghai, China
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Gao KM, Hu JJ, Lao J, Zhao X. Evaluation of nerve transfer options for treating total brachial plexus avulsion injury: A retrospective study of 73 participants. Neural Regen Res 2018; 13:470-476. [PMID: 29623932 PMCID: PMC5900510 DOI: 10.4103/1673-5374.228730] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Despite recent great progress in diagnosis and microsurgical repair, the prognosis in total brachial plexus-avulsion injury remains unfavorable. Insufficient number of donors and unreasonable use of donor nerves might be key factors. To identify an optimal treatment strategy for this condition, we conducted a retrospective review. Seventy-three patients with total brachial plexus avulsion injury were followed up for an average of 7.3 years. Our analysis demonstrated no significant difference in elbow-flexion recovery between phrenic nerve-transfer (25 cases), phrenic nerve-graft (19 cases), intercostal nerve (17 cases), or contralateral C7-transfer (12 cases) groups. Restoration of shoulder function was attempted through anterior accessory nerve (27 cases), posterior accessory nerve (10 cases), intercostal nerve (5 cases), or accessory + intercostal nerve transfer (31 cases). Accessory nerve + intercostal nerve transfer was the most effective method. A significantly greater amount of elbow extension was observed in patients with intercostal nerve transfer (25 cases) than in those with contralateral C7 transfer (10 cases). Recovery of median nerve function was noticeably better for those who received entire contralateral C7 transfer (33 cases) than for those who received partial contralateral C7 transfer (40 cases). Wrist and finger extension were reconstructed by intercostal nerve transfer (31 cases). Overall, the recommended surgical treatment for total brachial plexus-avulsion injury is phrenic nerve transfer for elbow flexion, accessory nerve + intercostal nerve transfer for shoulder function, intercostal nerves transfer for elbow extension, entire contralateral C7 transfer for median nerve function, and intercostal nerve transfer for finger extension. The trial was registered at ClinicalTrials.gov (identifier: NCT03166033).
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Affiliation(s)
- Kai-Ming Gao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jing-Jing Hu
- Department of Hand Surgery, Huashan Hospital, Fudan University; Nursing Department, Huashan Hospital, Fudan University, Shanghai, China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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Neurotização do nervo axilar por um ramo do tríceps: comparação entre acesso axilar e posterior. Rev Bras Ortop 2018. [DOI: 10.1016/j.rbo.2016.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Jiang Y, Lao J. The phrenic nerve transfer in the treatment of a septuagenarian with brachial plexus avulsion injury: a case report. Int J Neurosci 2017; 128:467-471. [PMID: 29077513 DOI: 10.1080/00207454.2017.1398154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Phrenic nerve transfer has been a well-established procedure for restoring elbow flexion function in patients with brachial plexus avulsion injury. Concerning about probably detrimental respiratory effects brought by the operation, however, stirred up quite a bit of controversy. We present a case report of the successful application of phrenic nerve as donor to reinnervate the biceps in a septuagenarian with brachial plexus avulsion injury, not accompanied with significant clinical respiratory problem.
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Affiliation(s)
- Ye Jiang
- a Department of Hand Surgery, Huashan Hospital , Fudan University , Shanghai , China.,b Key Laboratory of Hand Reconstruction , Ministry of Health , Shanghai , China.,c Shanghai Key Laboratory of Peripheral Nerve and Microsurgery , Shanghai , China
| | - Jie Lao
- a Department of Hand Surgery, Huashan Hospital , Fudan University , Shanghai , China.,b Key Laboratory of Hand Reconstruction , Ministry of Health , Shanghai , China.,c Shanghai Key Laboratory of Peripheral Nerve and Microsurgery , Shanghai , China
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Forli A, Bouyer M, Aribert M, Curvale C, Delord M, Corcella D, Moutet F. Upper limb nerve transfers: A review. HAND SURGERY & REHABILITATION 2017; 36:151-172. [DOI: 10.1016/j.hansur.2016.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/19/2016] [Accepted: 11/09/2016] [Indexed: 11/27/2022]
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Bhandari PS, Sadhotra LP, Bhargava P, Bath AS, Mukherjee MK, Bhatti TS, Maurya S. 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 2017. [DOI: 10.1016/s0973-0508(08)80008-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
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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Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Free Functioning Gracilis Muscle Transfer With and Without Simultaneous Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion After Traumatic Adult Brachial Pan-Plexus Injury. J Hand Surg Am 2017; 42:293.e1-293.e7. [PMID: 28249790 DOI: 10.1016/j.jhsa.2017.01.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 01/13/2017] [Accepted: 01/16/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE After complete 5-level root avulsion brachial plexus injury, the free-functioning muscle transfer (FFMT) and the intercostal nerve (ICN) to musculocutaneous nerve (MCN) transfer are 2 potential reconstructive options for restoration of elbow flexion. The aim of this study was to determine if the combination of the gracilis FFMT and the ICN to MCN transfer provides stronger elbow flexion compared with the gracilis FFMT alone. METHODS Sixty-five patients who underwent the gracilis FFMT only (32 patients) or the gracilis FFMT in addition to the ICN to MCN transfer (33 patients) for elbow flexion after a pan-plexus injury were included. The 2 groups were compared with respect to postoperative elbow flexion strength according to the modified British Medical Research Council grading system as well as preoperative and postoperative Disability of the Arm, Shoulder, and Hand scores. Two subgroup analyses were performed for the British Medical Research Council elbow flexion strength grade: FFMT neurotization (spinal accessory nerve vs ICN) and the attachment of the distal gracilis tendon (biceps tendon vs flexor digitorum profundus/flexor pollicis longus tendon). RESULTS The proportion of patients reaching the M3/M4 elbow flexion muscle grade were similar in both groups (FFMT vs FFMT + ICN to MCN transfer). Statistically significant improvement in postoperative Disability of the Arm, Shoulder, and Hand score was found in the FFMT + ICN to MCN transfer group but not in the FFMT group. There was a significant difference between gracilis to biceps (M3/M4 = 52.6%) and gracilis to FDP/flexor pollicis longus (M3/M4 = 85.2%) tendon attachment. CONCLUSIONS The use of the ICN to MCN transfer associated with the FFMT does not improve the elbow flexion modified British Medical Research Council grade, although better postoperative Disability of the Arm, Shoulder, and Hand scores were found in this group. The more distal attachment of the gracilis FFMT tendon may play an important role in elbow flexion strength. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Andrés A Maldonado
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Michelle F Kircher
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN
| | | | - Allen T Bishop
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN.
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35
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Kachramanoglou C, Carlstedt T, Koltzenburg M, Choi D. Long-Term Outcome of Brachial Plexus Reimplantation After Complete Brachial Plexus Avulsion Injury. World Neurosurg 2017; 103:28-36. [PMID: 28365432 PMCID: PMC5756545 DOI: 10.1016/j.wneu.2017.03.052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 12/04/2022]
Abstract
Background Complete brachial plexus avulsion injury is a severe disabling injury due to traction to the brachial plexus. Brachial plexus reimplantation is an emerging surgical technique for the management of complete brachial plexus avulsion injury. Objective We assessed the functional recovery in 15 patients who underwent brachial plexus reimplantation surgery after complete brachial plexus avulsion injury with clinical examination and electrophysiological testing. Methods We included all patients who underwent brachial plexus reimplantation in our institution between 1997 and 2010. Patients were assessed with detailed motor and sensory clinical examination and motor and sensory electrophysiological tests. Results We found that patients who had reimplantation surgery demonstrated an improvement in Medical Research Council power in the deltoid, pectoralis, and infraspinatous muscles and global Medical Research Council score. Eight patients achieved at least grade 3 MRC power in at least one muscle group of the arm. Improved reinnervation by electromyelography criteria was found in infraspinatous, biceps, and triceps muscles. There was evidence of ongoing innervation in 3 patients. Sensory testing in affected dermatomes also showed better recovery at C5, C6, and T1 dermatomes. The best recovery was seen in the C5 dermatome. Conclusions Our results demonstrate a definite but limited improvement in motor and sensory recovery after reimplantation surgery in patients with complete brachial plexus injury. We hypothesize that further improvement may be achieved by using regenerative cell technologies at the time of repair.
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Affiliation(s)
| | - Thomas Carlstedt
- Spinal Repair Unit, UCL Institute of Neurology, London, England, United Kingdom
| | - Martin Koltzenburg
- Spinal Repair Unit, UCL Institute of Neurology, London, England, United Kingdom
| | - David Choi
- Spinal Repair Unit, UCL Institute of Neurology, London, England, United Kingdom
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36
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Mathews AL, Yang G, Chang KWC, Chung KC. A systematic review of outcomes of contralateral C-7 transfer for the treatment of traumatic brachial plexus injury: an international comparison. J Neurosurg 2017; 126:922-932. [DOI: 10.3171/2016.1.jns152597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The effectiveness of contralateral C-7 (CC7) transfer is controversial, yet this procedure has been performed around the world to treat brachial plexus injuries. The authors performed a systematic review to study whether Asian countries reported better outcomes after CC7 transfer compared with “other” countries.
METHODS
A systematic literature search using PubMed, EMBASE, and 3 Chinese databases was completed. Patient outcomes of CC7 transfer to the median and musculocutaneous (MC) nerves were collected and categorized into 2 groups: Asia and “other” countries. China was included as a subcategory of Asia because investigators in China published the majority of the collected studies. To compare outcomes among studies, we created a normalized Medical Research Council (MRC) scale.
RESULTS
For median nerve outcomes, Asia reported that 41% of patients achieved an MRC grade of ≥ M3 of wrist flexion compared with 62% in “other” countries. For finger flexion, Asia found that 41% of patients reached an MRC grade of ≥ M3 compared with 38% in “other” countries. Asia reported that 60% of patients achieved ≥ S3 sensory recovery, compared with 32% in “other” countries. For MC nerve outcomes, 75% of patients from both Asia and “other” countries reached M4 and M3 in elbow flexion.
CONCLUSIONS
Current data did not demonstrate that studies from Asian countries reported better outcomes of CC7 transfer to the median and MC nerves. Future studies should focus on comparing outcomes of different surgical strategies for CC7 transfer.
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Affiliation(s)
- Alexandra L. Mathews
- 1Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School
| | - Guang Yang
- 2Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Kate Wan-Chu Chang
- 3Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, Ann Arbor, Michigan; and
| | - Kevin C. Chung
- 1Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical School
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Free Functioning Gracilis Muscle Transfer versus Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion after Traumatic Adult Brachial Pan-Plexus Injury. Plast Reconstr Surg 2016; 138:483e-488e. [DOI: 10.1097/prs.0000000000002471] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dual Nerve Transfers for Restoration of Shoulder Function After Brachial Plexus Avulsion Injury. Ann Plast Surg 2016; 76:668-73. [DOI: 10.1097/sap.0000000000000747] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Fang XY, Zhang WM, Zhang CF, Wong WM, Li W, Wu W, Lin JH. Lithium accelerates functional motor recovery by improving remyelination of regenerating axons following ventral root avulsion and reimplantation. Neuroscience 2016; 329:213-25. [PMID: 27185485 DOI: 10.1016/j.neuroscience.2016.05.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/12/2016] [Accepted: 05/06/2016] [Indexed: 01/14/2023]
Abstract
Brachial plexus injury (BPI) often involves the complete or partial avulsion of one or more of the cervical nerve roots, which leads to permanent paralysis of the innervated muscles. Reimplantation surgery has been attempted as a clinical treatment for brachial plexus root avulsion but has failed to achieve complete functional recovery. Lithium is a mood stabilizer drug that is used to treat bipolar disorder; however, its effects on spinal cord or peripheral nerve injuries have also been reported. The purpose of this study was to investigate whether lithium can improve functional motor recovery after ventral root avulsion and reimplantation in a rat model of BPI. The results showed that systemic treatment with a clinical dose of lithium promoted motor neuron outgrowth and increased the efficiency of motor unit regeneration through enhanced remyelination. An analysis of myelin-associated genes showed that the effects of lithium started during the early phase of remyelination and persisted through the late stage of the process. Efficient remyelination of the regenerated axons in the lithium-treated rats led to an earlier functional recovery. Therefore, we demonstrated that lithium might be a potential clinical treatment for BPI in combination with reimplantation surgery.
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Affiliation(s)
- Xin-Yu Fang
- The First Clinical Medical College of Fujian Medical University, Fuzhou, Fujian, China; School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Wen-Ming Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China; School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Chao-Fan Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China; Department of Orthopedics & Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Wai-Man Wong
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Wen Li
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region
| | - Wutian Wu
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region; State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Hong Kong Special Administrative Region; Joint Laboratory for CNS Regeneration, Jinan University and The University of Hong Kong, GHM Institute of CNS Regeneration, Jinan University, Guangzhou, China.
| | - Jian-Hua Lin
- Department of Orthopedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China.
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Abstract
The purpose of this article is to provide an overview of the various nerve transfer options for restoration of elbow function. This article describes nerve transfer strategies for elbow flexion and extension including the indications, limitations, and expected outcomes based on current literature.
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Affiliation(s)
- Liselotte F Bulstra
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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A Systematic Review of Outcomes of Contralateral C7 Transfer for the Treatment of Traumatic Brachial Plexus Injury: Part 2. Donor-Site Morbidity. Plast Reconstr Surg 2016; 136:480e-489e. [PMID: 26397267 DOI: 10.1097/prs.0000000000001616] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although contralateral C7 (CC7) transfer has been widely used for treating traumatic brachial plexus injury, the safety of the procedure is questionable. The authors performed a systematic review to investigate the donor-site morbidity, including sensory abnormality and motor deficit, to guide clinical decision-making. METHODS A systematic review on (CC7) transfer for traumatic brachial plexus injury was performed for original articles in the PubMed and Embase databases. Patient demographic data and donor-site morbidity of (CC7) transfer, including incidence, recovery rate, and recovery time were extracted. The sensory abnormality areas and muscles involved in motor weakness were also summarized. RESULTS A total of 904 patients from 27 studies were reviewed. Overall, 74 percent of patients (668 of 897) experienced sensory abnormalities, and 98 percent (618 of 633) recovered to normal; the mean recovery time was 3 months. For motor function, 20 percent (118 of 592) had motor deficit after (CC7) transfer and 91 percent (107 of 117) regained normal motor function; the mean recovery time was 6 months. Sensory abnormality mainly occurred in the area of the hand innervated by the median nerve, whereas motor deficit most often involved muscles innervated by the radial nerve. There were 19 patients with long-term morbidity of the donor site in the studies. CONCLUSIONS The incidence of donor-site morbidity after (CC7) transfer was relatively high, and severe and long-term defects occurred occasionally. (CC7) transfer should be indicated only when other donor nerves are not available, and with a comprehensive knowledge of the potential risks.
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Jiang Y, Wang L, Lao J, Zhao X. Comparative study of intercostal nerve transfer to lower trunk and contralateral C7 root transfer in repair of total brachial plexus injury in rats. J Plast Reconstr Aesthet Surg 2015; 69:623-8. [PMID: 26702947 DOI: 10.1016/j.bjps.2015.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 06/23/2015] [Accepted: 11/14/2015] [Indexed: 11/15/2022]
Abstract
AIM The aim of this study is to compare the treatment outcome of nerve transfer using intercostal nerves (ICNs) or contralateral C7 (cC7) root in rats. METHODS Ninety adult Sprague-Dawley rats were randomly divided into three groups of 30 each: group A (cC7 root transfer), group B (ICNs transfer), and group C (control). Electrophysiological examination, muscle tension test, neuromorphology, and muscle fiber cross-sectional area measurements obtained from the three groups were compared to evaluate neurotization outcome 4, 8, and 12 weeks postoperatively. RESULTS Median nerve regeneration and the flexor digitorum superficialis (FDS) muscle functional recovery of group B were worse than group A from comparison of both groups' parameters. CONCLUSIONS Neurotization of ICNs to the lower trunk is difficult to replace cC7 root transfer to the median nerve for restoration of hand function in total brachial plexus injury (BPI). Therefore, at present, the more important implication of the comparative study is that traditional cC7 root transfer remains the mainstay strategy to repair forearm flexor muscle function.
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Affiliation(s)
- Ye Jiang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Li Wang
- Department of Hand Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China.
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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A Systematic Review of Contralateral C7 Transfer for the Treatment of Traumatic Brachial Plexus Injury: Part 1. Overall Outcomes. Plast Reconstr Surg 2015; 136:794-809. [PMID: 26397253 DOI: 10.1097/prs.0000000000001494] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Contralateral C7 (CC7) transfer has been used for treating traumatic brachial plexus injury. However, the effectiveness of the procedure remains a subject of debate. The authors performed a systematic review to study the overall outcomes of CC7 transfer to different recipient nerves in traumatic brachial plexus injuries. METHODS A literature search was conducted using PubMed and EMBASE databases to identify original articles related to CC7 transfer for traumatic brachial plexus injury. The data extracted were study/patient characteristics, and objective outcomes of CC7 transfer to the recipient nerves. The authors normalized outcome measures into a Medical Research Council-based (MRC) outcome scale. RESULTS Thirty-nine studies were identified. The outcomes were categorized based on the major recipient nerves: median, musculocutaneous, and radial/triceps. Regarding overall functional recovery, 11 percent of patients achieved MRC grade M4 wrist flexion and 38 percent achieved MRC grade M3. Grade M4 finger flexion was achieved by 7 percent of patients, whereas 36 percent achieved M3. Finally, 56 percent achieved greater than or equal to S3 sensory recovery in the median nerve territories. In the musculocutaneous nerve group, 38 percent regained to M4 and 37 percent regained to M3. In the radial/triceps nerve group, 25 percent regained elbow or wrist extension strength to a MRC grade M4 and to M3, respectively. CONCLUSIONS Outcome measures in the included studies were not consistently reported to uncover true patient-related benefits from the CC7 transfer. Reliable and validated outcome instruments should be applied to critically evaluate patients undergoing CC7 transfer.
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Abstract
Abstract
Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.
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Affiliation(s)
- Wilson Z. Ray
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jason Chang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ammar Hawasli
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas J. Wilson
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lynda Yang
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
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Socolovsky M, di Masi G, Bonilla G, Paez MD, Robla J, Cabrera CC. The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis. Acta Neurochir (Wien) 2015; 157:1077-86; discussion 1086. [PMID: 25833303 DOI: 10.1007/s00701-015-2387-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Controversy exists surrounding the use of the phrenic nerve for transfer in severe brachial plexus injuries. The objectives of this study are: (1) to present the experience of the authors using the phrenic nerve in a single institution; and (2) to thoroughly review the existing literature to date. METHODS Adult patients with C5-D1 and C5-C8 lesions and a phrenic nerve transfer were retrospectively included. Patients with follow-up shorter than 18 months were excluded. The MRC muscle strength grading system was used to rate the outcome. Clinical repercussions relating to sectioning of the phrenic nerve were studied. An intense rehabilitation program was started after surgery, and compliance to this program was monitored using a previously described scale. Statistical analysis was performed with the obtained data. RESULTS Fifty-one patients were included. The mean time between trauma and surgery was 5.7 months. Three-quarters of the patients had C5-D1, with the remainder C5-C8. Mean post-operative follow-up was 32.5 months A MRC of M4 was achieved in 62.7% patients, M3 21.6%, M2 in 3.9%, and M1 in 11.8%. The only significant differences between the two groups were in graft length (9.8 vs. 15.1 cm, p = 0.01); and in the rehabilitation compliance score (2.86 vs. 2.00, p = 0.01). CONCLUSIONS Results of phrenic nerve transfer are predictable and good, especially if the grafts are short and the rehabilitation is adequate. It may adversely affect respiratory function tests, but this rarely correlates clinically. Contraindications to the use of the phrenic nerve exist and should be respected.
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Liu Y, Xu XC, Zou Y, Li SR, Zhang B, Wang Y. Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics. Neural Regen Res 2015; 10:328-33. [PMID: 25883637 PMCID: PMC4392686 DOI: 10.4103/1673-5374.152388] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2014] [Indexed: 11/04/2022] Open
Abstract
Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering 'excellent' and 'good' muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.
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Affiliation(s)
- Ying Liu
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Xun-Cheng Xu
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Yi Zou
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Su-Rong Li
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Bin Zhang
- Department of Orthopedics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
| | - Yue Wang
- Department of Orthopedics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, China
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Comparative study of phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury. Injury 2015; 46:671-5. [PMID: 25554421 DOI: 10.1016/j.injury.2014.11.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 11/22/2014] [Accepted: 11/27/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Global brachial plexus injuries (BPIs) are devastating events frequently resulting in severe functional impairment. The widely used nerve transfer sources for elbow flexion in patients with global BPIs include intercostal and phrenic nerves. OBJECTIVE The aim of this study was to compare phrenic and intercostal nerve transfers for elbow flexion after global BPI. METHODS A retrospective review of 33 patients treated with phrenic and intercostal nerve transfer for elbow flexion in posttraumatic global root avulsion BPI was carried out. In the phrenic nerve transfer group, the phrenic nerve was transferred to the anterolateral bundle of the anterior division of the upper trunk (23 patients); in the intercostal nerve transfer group, three intercostal nerves were coapted to the anterolateral bundles of the musculocutaneous nerve. The British Medical Research Council (MRC) grading system, angle of elbow flexion, and electromyography (EMG) were used to evaluate the recovery of elbow flexion at least 3 years postoperatively. RESULTS The efficiency of motor function in the phrenic nerve transfer group was 83%, while it was 70% in the intercostal nerve transfer group. The two groups were not statistically different in terms of the MRC grade (p=0.646) and EMG results (p=0.646). The outstanding rates of angle of elbow flexion were 48% and 40% in the phrenic and intercostal nerve transfer groups, respectively. There was no significant difference of outstanding rates in the angle of elbow flexion between the two groups. CONCLUSION Phrenic nerve transfer had a higher proportion of good prognosis for elbow flexion than intercostal nerve transfer, but the effective and outstanding rate had no significant difference for biceps reinnervation between the two groups according to MRC grading, angle of elbow flexion, and EMG.
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Ali ZS, Heuer GG, Faught RWF, Kaneriya SH, Sheikh UA, Syed IS, Stein SC, Zager EL. Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques. J Neurosurg 2015; 122:195-201. [PMID: 25361485 DOI: 10.3171/2014.9.jns132823] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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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Affiliation(s)
- Zarina S Ali
- Department of Neurosurgery, University of Pennsylvania; and
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Optimal Axon Counts for Brachial Plexus Nerve Transfers to Restore Elbow Flexion. Plast Reconstr Surg 2015; 135:135e-141e. [DOI: 10.1097/prs.0000000000000795] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Does nerve repair or transfer really help in birth associated brachial plexus injury (obstetric palsy)? Current evidence. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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