Nerve Graft Length and Recovery of Elbow Flexion Muscle Strength in Patients With Traumatic Brachial Plexus Injuries: Case Series

2021 ◽  
Author(s):  
Mariano Socolovsky ◽  
Gilda di Masi ◽  
Gonzalo Bonilla ◽  
Ana Lovaglio ◽  
Kartik G Krishnan
Keyword(s):  
Brachial Plexus ◽  
Case Series ◽  
Target Function ◽  
Elbow Flexion ◽  
Nerve Graft ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Nerve Reconstruction ◽  
Muscle Recovery ◽  
Spinal Accessory

Abstract BACKGROUND Traumatic brachial plexus injuries cause long-term maiming of patients. The major target function to restore in complex brachial plexus injury is elbow flexion. OBJECTIVE To retrospectively analyze the correlation between the length of the nerve graft and the strength of target muscle recovery in extraplexual and intraplexual nerve transfers. METHODS A total of 51 patients with complete or near-complete brachial plexus injuries were treated with a combination of nerve reconstruction strategies. The phrenic nerve (PN) was used as axon donor in 40 patients and the spinal accessory nerve was used in 11 patients. The recipient nerves were the anterior division of the upper trunk (AD), the musculocutaneous nerve (MC), or the biceps branches of the MC (BBs). An index comparing the strength of elbow flexion between the affected and the healthy arms was correlated with the choice of target nerve recipient and the length of nerve grafts, among other parameters. The mean follow-up was 4 yr. RESULTS Neither the choice of MC or BB as a recipient nor the length of the nerve graft showed a strong correlation with the strength of elbow flexion. The choice of very proximal recipient nerve (AD) led to axonal misrouting in 25% of the patients in whom no graft was employed. CONCLUSION The length of the nerve graft is not a negative factor for obtaining good muscle recovery for elbow flexion when using PN or spinal accessory nerve as axon donors in traumatic brachial plexus injuries.

Reliability of functioning free muscle transfer and vascularized ulnar nerve grafting for elbow flexion in complete brachial plexus palsy

2017 ◽  
Vol 42 (7) ◽  
pp. 693-699 ◽  
Author(s):  
S. M. Potter ◽  
S. I. Ferris
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Brachial Plexus Injury ◽  
Elbow Flexion ◽  
Nerve Graft ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Muscle Transfer ◽  
Spinal Accessory ◽  
Nerve Grafts

We compared outcomes of primary vascularized ulnar nerve grafts from the C5 root neurotizing biceps and brachialis muscles, and gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve, as a primary or salvage procedure after complete brachial plexus injury. At 45 months, three of eight primary vascularized ulnar nerve graft patients regained grade 4 elbow flexion, while one regained grade 3. All 13 primary gracilis transfer patients regained grade 4 elbow flexion. Four patients with vascularized ulnar nerve grafts failed and subsequently had salvage functioning free muscle transfer procedures resulting in delayed recovery. Although vascularized ulnar nerve graft-based primary reconstructions can provide useful elbow flexion, this was achieved in less than half the cases. We consider primary gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve as the most reliable reconstruction for the restoration of elbow flexion in complete brachial plexus injury. Level of evidence: IV

Distal transfers as a primary treatment in obstetric brachial plexus palsy: a series of 20 cases

2016 ◽  
Vol 41 (8) ◽  
pp. 875-881 ◽  
Author(s):  
B. A. Ghanghurde ◽  
R. Mehta ◽  
K. M. Ladkat ◽  
B. B. Raut ◽  
M. R. Thatte
Keyword(s):  
Brachial Plexus ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Primary Treatment ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Type I ◽  
Spinal Accessory ◽  
Obstetric Brachial Plexus

The purpose of this study was to examine the results of spinal accessory nerve to suprascapular nerve (with or without axillary nerve neurotization) and an Oberlin transfer as primary treatment in children with Narakas type I obstetric brachial plexus injuries, when parents refused to consent to conventional nerve trunk-/root-level reconstruction. A total of 20 children with poor shoulder abduction and no biceps antigravity function but with good hand function were treated with spinal accessory nerve to suprascapular nerve and an Oberlin transfer at a mean age of 5.8 months (SD 3.27; range 3–12.) All the patients were evaluated at a mean of 2.8 years (SD 0.8; range 1.5 to 3.8) post-operatively. Three patients were lost to follow-up. Of the remainder, 11 had grade 4+ power of elbow flexion and six patients had grade 4 power at 1 year follow-up; all had 4+ power of elbow flexion at final follow-up. At final follow-up the Mallet score was a mean of 15; (SD 4.22, range 9 to 20). Primary distal nerve transfers can give good outcomes in patients with obstetric brachial plexus injuries and may be an alternative to surgery on the nerve trunks Level of evidence: IV

scholarly journals Results of spinal accessory to suprascapular nerve transfer in 110 patients with complete palsy of the brachial plexus

2016 ◽  
Vol 24 (6) ◽  
pp. 990-995 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Suprascapular Nerve ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Spinal Accessory ◽  
Extended Approach ◽  
The Mean

OBJECTIVE Transfer of the spinal accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with total brachial plexus palsy. However, the results of this procedure remain largely unknown. METHODS Over an 11-year period (2002–2012), 257 patients with total brachial plexus palsy were operated upon in the authors' department by a single surgeon and had the spinal accessory nerve transferred to the suprascapular nerve. Among these, 110 had adequate follow-up and were included in this study. Their average age was 26 years (SD 8.4 years), and the mean interval between their injury and surgery was 5.2 months (SD 2.4 months). Prior to 2005, the suprascapular and spinal accessory nerves were dissected through a classic supraclavicular L-shape incision (n = 29). Afterward (n = 81), the spinal accessory and suprascapular nerves were dissected via an oblique incision, extending from the point at which the plexus crossed the clavicle to the anterior border of the trapezius muscle. In 17 of these patients, because of clavicle fractures or dislocation, scapular fractures or retroclavicular scarring, the incision was extended by detaching the trapezius from the clavicle to expose the suprascapular nerve at the suprascapular fossa. In all patients, the brachial plexus was explored and elbow flexion reconstructed by root grafting (n = 95), root grafting and phrenic nerve transfer (n = 6), phrenic nerve transfer (n = 1), or third, fourth, and fifth intercostal nerve transfer. Postoperatively, patients were followed for an average of 40 months (SD 13.7 months). RESULTS Failed recovery, meaning less than 30° abduction, was observed in 10 (9%) of the 110 patients. The failure rate was 25% between 2002 and 2004, but dropped to 5% after the staged/extended approach was introduced. The mean overall range of abduction recovery was 58.5° (SD 26°). Comparing before and after distal suprascapular nerve exploration (2005–2012), the range of abduction recovery was 45° (SD 25.1°) versus 62° (SD 25.3°), respectively (p = 0.002). In patients who recovered at least 30° of abduction, recovery of elbow flexion to at least an M3 level of strength increased the range of abduction by an average of 13° (p = 0.01). Before the extended approach, 2 (7%) of 29 patients recovered active external rotation of 20° and 120°. With the staged/extended approach, 32 (40%) of 81 recovered some degree of active external rotation. In these patients, the average range of motion measured from the thorax was 87° (SD 40.6°). CONCLUSIONS In total palsies of the brachial plexus, using the spinal accessory nerve for transfer to the suprascapular nerve is reliable and provides some recovery of abduction for a large majority of patients. In a few patients, a more extensive approach to access the suprascapular nerve, including, if necessary, dissection in the suprascapular fossa, may enhance outcomes.

scholarly journals Spinal Accessory Nerve to Triceps Transfer for Recovery of Elbow Extension in Traumatic Brachial Plexus Injuries

2017 ◽  
Vol 42 (9) ◽  
pp. S32 ◽  
Author(s):  
Liselotte Bulstra ◽  
Nadia Rbia ◽  
Femke Mathot ◽  
Robert Spinner ◽  
Allen T. Bishop ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Elbow Extension ◽  
Spinal Accessory

Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk

2019 ◽  
Vol 31 (1) ◽  
pp. 133-138 ◽  
Author(s):  
Johannes A. Mayer ◽  
Laura A. Hruby ◽  
Stefan Salminger ◽  
Gerd Bodner ◽  
Oskar C. Aszmann
Keyword(s):  
Brachial Plexus ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Axillary Nerve ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Nerve Function ◽  
Analog Scale ◽  
Spinal Accessory ◽  
Active Range Of Motion

OBJECTIVESpinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle.METHODSFive cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented.RESULTSAll 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients.CONCLUSIONSRestoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.

Anatomical variations of the spinal accessory nerve and its relevance to level IIb lymph nodes

2009 ◽  
Vol 141 (5) ◽  
pp. 639-644 ◽  
Author(s):  
Sang Hyuk Lee ◽  
Jong Kyu Lee ◽  
Sung Min Jin ◽  
Jin Hwan Kim ◽  
Il Seok Park ◽  
...  
Keyword(s):  
Lymph Nodes ◽  
Case Series ◽  
Anatomical Variations ◽  
Ventral Side ◽  
Spinal Accessory Nerve ◽  
Accessory Nerve ◽  
Cervical Plexus ◽  
Spinal Accessory ◽  
Adjacent Structures ◽  
Inferior Border

Objective: This study was conducted to identify anatomical variations of the spinal accessory nerve (SAN) in the upper neck, the landmark of the anterior and inferior border of level IIb, and to evaluate the nerve's effect on the border and the number of lymph nodes (LNs) in level IIb. Study Design and Setting: Case series with planned data collection. Subjects and Methods: A total of 181 neck dissections (NDs) were prospectively enrolled in this study. The relation between the SAN and adjacent structures (internal jugular vein [IJV], sternocleidomastoid muscle [SCM], cervical plexus) and the number of LNs in level IIb was investigated. Results: The SAN crossed the IJV ventrally in 72 cases (39.8%) and dorsally in 104 cases (57.4%), and passed through the IJV in five cases (2.8%). The SAN ran along the inner surface of the SCM and sent branches to the SCM without penetration of the muscle in 83 cases (45.9%), whereas in 98 cases (54.1%) the nerve sent branches to the SCM by penetration. Cervical plexus contribution to the SAN was seen from C2 in 96 cases (53.1%), C2 and C3 in 69 cases (38.1%), and C3 in 16 cases (8.8%). The mean number of LNs of level IIa and level IIb was 6.5 and 8.2 in cases in which the SAN crossed the IJV ventrally, and 6.8 and 5.4 in dorsally crossing cases. LNs included in the neck level IIb in ventrally crossing SAN cases were significantly larger than the dorsally crossing cases ( P < 0.05). Conclusions: Our results may help to minimize the incidence of injuring the SAN in the upper neck during ND. Neck level IIb would contain more LNs if the course of the nerve leans toward the ventral side.

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