scholarly journals Restoration of Elbow Flexion for Upper Trunk Brachial Plexus Injuries: Evaluation of Nerve Transfers and Modified Steindler Flexorplasty

2021 ◽  
Vol 55 (3) ◽  
Author(s):  
Precious Grace B. Handog ◽  
Tristram D. Montales ◽  
Emmanuel P. Estrella
Keyword(s):  
Brachial Plexus ◽  
Range Of Motion ◽  
Elbow Flexion ◽  
Manual Muscle Testing ◽  
Dash Score ◽  
Delayed Presentation ◽  
Surgical Delay ◽  
Nerve Transfers ◽  
Muscle Testing

Introduction. In patients with delayed presentation between 6 to 12 months, surgical treatment guidelines are not well defined in brachial plexus injury. Still, several authors have agreed that functional outcomes in patients treated within six months from the date of injury have the best results. Nerve transfers are still considered one of the treatment options in the said subset of patients even after six months. In contrast, a primary Steindler flexorplasty, or proximal advancement of the flexor-pronator group, is an ideal technique for elbow flexion with an elapsed time from injury >6 to 9 months. Objective. The purpose of this investigation was to compare the clinical outcome s of nerve transfers versus modified Steindler flexorplasty for the restoration of elbow flexion in upper type brachial plexus injuries (BPI). Methods. A retrospective review of 28 patients who underwent nerve transfers (NT) and 12 patients who underwent modified Steindler flexorplasty (MSF) was done to determine the outcome of treatments. The manual muscle testing using the Medical Research Council scaling system, Visual Analog Scale for pain, active range of motion, and Disabilities of the Arm, Shoulder and Hand form scores were taken as dependent variables. Results. The NT group had a median age of 27.5 years, with 26 men, a median surgical delay of 5.6 months, and a median follow-up of 33 months. Twenty out of 28 patients (71%) had ≥M3 with a median range of 117.6° elbow flexion motion. Median postoperative DASH (n=16) and VAS scores were 29.2 and 3, respectively. For the MSF patients, the median age was 27 years, including ten men, the median surgical delay was 12 months, and the median follow-up was 18.4 months. All the 12 patients had ≥M3, with a median range of motion of 106°. The median postoperative DASH score (n=5) and VAS score were 28.3 and 0, respectively. In the NT group, 73.3% (11/15) achieved ≥M3 elbow flexion if the operation was done in <6 months. Conclusion. Nerve transfers and the modified Steindler procedure are still excellent options for successful elbow flexion reanimation in patients with brachial plexus injuries. Our results also showed that those with surgical delays of less than six months had the highest rate of achieving ≥M3 elbow flexion strength in the nerve transfer group.

NERVE TRANSFER SURGERY FOR ADULT BRACHIAL PLEXUS INJURY

Neurosurgery ◽  
2009 ◽  
Vol 65 (suppl_4) ◽  
pp. A55-A62 ◽  
Author(s):  
Olawale A.R. Sulaiman ◽  
Daniel D. Kim ◽  
Clint Burkett ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Research Council ◽  
Medical Research Council ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Nerve Transfers ◽  
Direct Repair ◽  
Grade 3

Abstract OBJECTIVE To review the clinical outcomes in our patients who have undergone nerve transfer operations for brachial plexus reconstruction at the Louisiana State University (LSU) over a 10-year period. A secondary objective is to compare clinical outcomes in patients who had only nerve transfer operations as compared with patients whose nerve transfers were supplemented with direct repair of brachial plexus elements. METHODS Retrospective review of the medical records, imaging, and electrodiagnostic studies (electromyographic and nerve conduction studies) of patients with brachial plexus injuries who underwent nerve transfer operations at LSU over a period of 10 years. RESULTS A total of 81 patients were treated between 1995 to 2005 at the LSU Health Sciences Center; 7 of these patients were lost to follow-up, leaving 74 patients, with an average follow-up of 3.5 years, for review. We evaluated recovery of elbow flexion and shoulder abduction. Ninety percent of patients with medial pectoral to musculocutaneous nerve transfers recovered to LSU grade 2 (Medical Research Council grade 3), and 60% of those patients with intercostal to musculocutaneous nerve transfer regained similar strength in elbow flexion. Shoulder abduction recovery to LSU grade 2 (Medical Research Council grade 3) after spinal accessory to suprascapular and/or thoracodorsal to axillary nerve transfer, was 95% and 36%, respectively. There was a tendency for better motor recovery when nerve transfer operations were combined with direct repair of plexus elements. CONCLUSION Nerve transfers for repair of brachial plexus injuries result in excellent recovery of elbow and shoulder functions. Patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.

Analysis of human acellular nerve allograft combined with contralateral C7 nerve root transfer for restoration of shoulder abduction and elbow flexion in brachial plexus injury: a mean 4-year follow-up

2020 ◽  
Vol 132 (6) ◽  
pp. 1914-1924 ◽  
Author(s):  
Liang Li ◽  
Jiantao Yang ◽  
Bengang Qin ◽  
Honggang Wang ◽  
Yi Yang ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Functional Outcomes ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Allograft Reconstruction ◽  
Acellular Nerve Allograft ◽  
The Mean ◽  
Monofilament Test

OBJECTIVEHuman acellular nerve allograft applications have increased in clinical practice, but no studies have quantified their influence on reconstruction outcomes for high-level, greater, and mixed nerves, especially the brachial plexus. The authors investigated the functional outcomes of human acellular nerve allograft reconstruction for nerve gaps in patients with brachial plexus injury (BPI) undergoing contralateral C7 (CC7) nerve root transfer to innervate the upper trunk, and they determined the independent predictors of recovery in shoulder abduction and elbow flexion.METHODSForty-five patients with partial or total BPI were eligible for this retrospective study after CC7 nerve root transfer to the upper trunk using human acellular nerve allografts. Deltoid and biceps muscle strength, degree of shoulder abduction and elbow flexion, Semmes-Weinstein monofilament test, and static two-point discrimination (S2PD) were examined according to the modified British Medical Research Council (mBMRC) scoring system, and disabilities of the arm, shoulder, and hand (DASH) were scored to establish the function of the affected upper limb. Meaningful recovery was defined as grades of M3–M5 or S3–S4 based on the scoring system. Subgroup analysis and univariate and multivariate logistic regression analyses were conducted to identify predictors of human acellular nerve allograft reconstruction.RESULTSThe mean follow-up duration and the mean human acellular nerve allograft length were 48.1 ± 10.1 months and 30.9 ± 5.9 mm, respectively. Deltoid and biceps muscle strength was grade M4 or M3 in 71.1% and 60.0% of patients. Patients in the following groups achieved a higher rate of meaningful recovery in deltoid and biceps strength, as well as lower DASH scores (p < 0.01): age < 20 years and age 20–29 years; allograft lengths ≤ 30 mm; and patients in whom the interval between injury and surgery was < 90 days. The meaningful sensory recovery rate was approximately 70% in the Semmes-Weinstein monofilament test and S2PD. According to univariate and multivariate logistic regression analyses, age, interval between injury and surgery, and allograft length significantly influenced functional outcomes.CONCLUSIONSHuman acellular nerve allografts offered safe reconstruction for 20- to 50-mm nerve gaps in procedures for CC7 nerve root transfer to repair the upper trunk after BPI. The group in which allograft lengths were ≤ 30 mm achieved better functional outcome than others, and the recommended length of allograft in this procedure was less than 30 mm. Age, interval between injury and surgery, and allograft length were independent predictors of functional outcomes after human acellular nerve allograft reconstruction.

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

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

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

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

2004 ◽  
Vol 101 (5) ◽  
pp. 770-778 ◽  
Author(s):  
Jayme Augusto Bertelli ◽  
Marcos Flávio Ghizoni
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Phrenic Nerve ◽  
Cranial Nerve ◽  
External Rotation ◽  
Elbow Flexion ◽  
Content Type ◽  
Nerve Transfers ◽  
Contralateral Motor ◽  
Fine Print

Object. The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. Methods. Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90° and 92° in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70°. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3+ and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. Conclusions. Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.

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

2004 ◽  
Vol 16 (5) ◽  
pp. 313-318
Author(s):  
Thomas H. Tung ◽  
Christine B. Novak ◽  
Susan E. Mackinnon
Keyword(s):  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Elbow Flexion ◽  
Musculocutaneous Nerve ◽  
Nerve Transfers ◽  
Brachialis Muscle ◽  
Nerve Fascicle ◽  
The Mean ◽  
Mean Time ◽  
Flexion Strength

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

Shoulder girdle impairment in breast cancer survivors: the role of range of motion as predictive factor for dose distribution and clinical outcome

2019 ◽  
Vol 105 (4) ◽  
pp. 319-330 ◽  
Author(s):  
Fabio Marazzi ◽  
Valeria Masiello ◽  
Domenico Marchesano ◽  
Luca Boldrini ◽  
Stefano Luzi ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Range Of Motion ◽  
Functional Impairment ◽  
Predictive Factor ◽  
Late Complication ◽  
Shoulder Girdle ◽  
Dash Score ◽  
Observational Analysis ◽  
Significant Difference

Background:Pain and functional impairment of the ipsilateral shoulder girdle in patients who underwent surgery and radiotherapy for breast cancer (BC) is a late complication reported in the literature. We analyze a correlation with dosimetric parameters and propose an algorithm for sparing strategies.Methods:A total of 111 patients treated for BC were included in this observational analysis during follow-up protocol visits. Exclusion criteria were the presence of moderate or severe arthrosis history and/or rheumatologic diseases. All the patients had complete physical and multidimensional examinations during joint (physiatrist and radiotherapy oncology) follow-up visits. A scapula–humeral articulation (SHA) standardized contouring was performed retrospectively on Eclipse® treatment plans. A possible correlation between patients’ characteristics, radiotherapy, and dosimetry analysis and functional impairment was investigated at statistical analysis. Results of analysis were summarized into a proposal of algorithm for sparing SHA.Results:A total of 111 patients were selected during follow-up visits. Mean age of patients was 60 years (range 41–85 years). A total of 103 patients (93%) underwent conservative surgery, with 110 patients (99%) undergoing axilla surgery as well. Fifty-two patients (46.8%) presented a reduction of range of motion (ROM) abduction on the treated side at the observational analysis. Mean ROM abduction reduction was 13°06’ (range 0°–100°). Disability of the Arm, Shoulder and Hand questionnaire (DASH) score results were excellent in 79 patients (71.2%), discrete in 15 patients (13.5%), good in 15 patients (13.5%), and sufficient in 2 patients (1.8%). Median EQD2Dmaxat SHA was 18 Gy (range 0.22–51.9 Gy) and median EQD2mean dose at SHA was 2 Gy (range 0.04–24.32 Gy). Univariate analysis showed a linear correlation between DASH score and ROM of abduction of treated side (ρ=−0.7), ROM of abduction and ROM of flexion in ipsilateral arm (ρ=0.8), or ROM of abduction and ROM of flexion in contralateral arm (ρ=0.8). A statistically significant difference in ROM abduction between the 2 arms was found at χ2test ( P<0.05 at χ2confidence interval = 95%). Cox linear regression analysis showed ROM abduction on treated arm as a predictive factor of DASH score ( P<0.0001). Age ( P<0.05), DASH score ( P=0.006), and ROM abduction on treated arm ( P=0.005) were found as independent predictive factors of mean dose at multivariate analysis. A mean dose higher than 7 Gy and ROM abduction reduction more than 30° were related to DASH score level reduction.Conclusions:This hypothesis-generating study introduces an algorithm to be validated for management of sparing SHA and improving quality of survivorship. ROM evaluation after surgery, early physiotherapy, standard contouring, and planning adaptation represent possible indications to preserve shoulder impairment. Further prospective studies are needed to discriminate impairment of surgery and radiotherapy in order to personalized therapeutic plan programs.

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

2019 ◽  
Vol 24 (03) ◽  
pp. 283-288
Author(s):  
Yusuke Nagano ◽  
Daisuke Kawamura ◽  
Alaa Terkawi ◽  
Atsushi Urita ◽  
Yuichiro Matsui ◽  
...  
Keyword(s):  
Muscle Strength ◽  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Functional Outcomes ◽  
Brachial Plexus Injury ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
The Mean ◽  
Flexion Strength

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

Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series

2020 ◽  
Vol 19 (3) ◽  
pp. 249-254
Author(s):  
Mariano Socolovsky ◽  
Marcio de Mendonça Cardoso ◽  
Ana Lovaglio ◽  
Gilda di Masi ◽  
Gonzalo Bonilla ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Phrenic Nerve ◽  
Case Series ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Nerve Section ◽  
Video Assisted ◽  
Significant Difference ◽  
Flexion Strength

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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