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PubMed1995

The effect of unilateral intercostal nerve transfer upon lung function.

Intercostal nerve transfer is a well-established technique in the treatment of some severe brachial plexus lesions in adults. There is, however, concern that in the presence of an ipsilateral phrenic nerve palsy it may lead to a significant compromise of respiratory function. 20 patients having intercostal nerve transfers had their lung function assessed pre-operatively and 6 weeks post-operatively. The patients were subsequently questioned about symptoms of respiratory dysfunction. There was no evidence that intercostal nerve transfer leads to a significant reduction in respiratory function in adults. It therefore appears safe to perform intercostal nerve transfers in adults following brachial plexus injuries even in the presence of an ipsilateral phrenic nerve palsy.

Adolescent↗
PubMed2003

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study.

PURPOSE: To experimentally evaluate the feasibility of restoring the motor function of the deltoid muscle in patients with complete C5-C6 root injury (upper brachial plexus injury) by transferring the nerve to the long head of the triceps to the anterior branch of the axillary nerve through a posterior approach. METHODS: The study was performed on shoulder girdles of 36 formalin-embalmed cadavers. The number, diameter, and length of the branches of the axillary nerve at the level of the quadrilateral space were noted. The length and diameter of the nerves to the long head and to the lateral head of triceps at the level of triangular space were recorded. The distances from the acromion angle to the bifurcation of the anterior branch of the axillary nerve, to the origins of the nerve to the long head, and to the origin of the lateral head of the triceps were recorded as well. Nerve biopsy specimens of the axillary nerve and the nerve to the long head of the triceps were obtained from 6 fresh cadavers for histomorphometric evaluation. RESULTS: The average length of the anterior branch of the axillary nerve in this study, measured from the quadrilateral space to the innervating site, was 44.5 mm (range, 26-62 mm), and the average length of the nerve to the long head of triceps, measured from its origin to the innervating site, was 68.5 mm (range, 30-69 mm). The average diameter of the anterior branches of the axillary nerve and the nerve to the long head of the triceps were 2.1 and 1.1 mm, respectively. The average number of axon fibers in the anterior branch of the axillary nerve was 2,704 and in the nerve to the long head of the triceps was 1,233. CONCLUSIONS: Using the acromial angle as the landmark, the combined length of the two 2 nerves was longer than the distance between them. The diameter, the number of axons, and the anatomic proximity of the nerve to the long head of the triceps make it a potential source for reinnervation of the anterior branch of the axillary nerve by direct nerve transfer without nerve grafting through posterior approach for the management of upper brachial plexus injuries.

Axilla↗
PubMed2003

[Nerve transfer in brachial plexus injuries--comparative analysis of surgical procedures].

Nerve transfer is the only possibility for nerve repair in cases of the brachial plexus traction injuries with spinal roots avulsion. From 1980. until 2000. in Institute of Neurosurgery, Clinical Center of Serbia, nerve transfer has been performed in 127(79%) of 159 patients with traction injuries of brachial plexus, i.e., 204 reinnervation procedures has been performed using different donor nerves. We achieved good or satisfactory arm abduction and full range or satisfactory elbow flexion through reinnervation of the axillary and musculocutaneous nerve using different donor nerves in 143 of 204 reinnervations, which presents general rate of useful functional recovery in 70.1% of cases. Mean values of the rate of useful functional recovery in individual modalities of nerve transfer in our series are 50.1% for intercostal and/or spinal accessory nerve transfer, 64.5% for plexo-plexal nerve transfer, 81.7% for regional nerve transfer, and 87.1% for combine nerve transfer.

Brachial Plexus↗
PubMed2004

Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results.

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle <M(3). We recommend Oberlin's ulnar nerve transfer for upper-type obstetric brachial plexus palsy in 1). breech delivery with avulsion of C5 and C6 nerve roots,) late presentation with good recovery of shoulder function, and 3). neuroma-in-continuity of the upper trunk with intraoperative good nerve conduction for the shoulder muscles, the same as preoperative good shoulder function but with no biceps action.

Brachial Plexus Neuropathies↗
PubMed2006

Neuronal survival, regeneration and musclemorphology after posterior C7 nerve transfer: an experimental study.

C7 nerve transfer has been widely used in treating brachial plexus avulsion injuries. Little is known regarding the survival and regeneration of C7 motor and sensory neurons including their morphological changes after this procedure and also the possible change of muscle fibre phenotype. In this experimental study, the posterior division of C7 nerve was transferred to the musculocutaneous nerve ipsilaterally, and using fluorescent tracing techniques, the C7 spinal cord segment and dorsal root ganglion were found to contain 630.9 +/- 86.7 motor neurons and 3916.0 +/- 517.3 sensory neurons, respectively. Six months following transfer, 90% of the motor neurons and 78% of the sensory neurons survived and approximately 40% of them had regenerated and all displayed normal soma size. After posterior C7 transfer and reinnervation, the target muscles showed a percentage pattern of distribution and mean fibre diameters similar to those seen in normal biceps muscle. The present study suggests that the posterior C7 nerve transfer provides sufficient number of neurons and satisfactory results for regeneration to obtain an acceptable functional recovery.

Animals↗
PubMed2006

Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies.

BACKGROUND: Restoration of elbow flexion is the main objective in the treatment of brachial plexus palsies affecting the upper roots. Transfer of the ulnar nerve to the nerve of the biceps has given satisfactory results, but the restored biceps is often weak in cases with avulsions of the C5-C6-C7 roots, in elderly patients, and after long preoperative delays. The authors decided to investigate a double nerve transfer: one or more fascicles of the ulnar nerve to the nerve to the biceps and a fascicle of the median nerve to the motor branch to the brachialis muscle. METHODS: The authors operated on 15 patients using this technique. The authors have follow-up of more than 6 months in 10 of them. Six had C5-C6 injuries, three had C5-C6-C7 palsies, and one had sustained an infraclavicular injury. The average age was 27.2 years. The average delay before surgery was 6.6 months. The average follow-up was 12.1 months. RESULTS: Grade 4 elbow flexion was restored in each of the 10 patients. In 10 cases, the patients were able to lift 1 to 5 kg. There was no secondary deficit in grip strength or sensation. CONCLUSIONS: The results of this technique compare favorably with those of other methods. The percentage of success and the strength of elbow flexion restored were increased without any morbidity. This technique will probably reduce the need for secondary procedures to augment elbow flexion. The authors propose double nerve transfer as a standard procedure in C5-C6 and C5-C6-C7 injuries.

Adult↗
PubMed2005

The use of thoracodorsal nerve transfer in restoration of irreparable C5 and C6 spinal nerve lesions.

There are only a few reports on the use of thoracodorsal nerve (TDN) transfer to the musculocutaneous or axillary nerves in cases of directly irreparable brachial plexus injuries. In this study, we analysed outcome and time-course of recovery in correlation with recipient nerves and type of nerve transfer (isolated or in combination with other collateral branches) for 27 patients with transfer to the musculocutaneous or axillary nerves. Using this nerve as donor, we obtained useful functional recovery in all 12 cases for the musculocutaneous nerve, and in 14 (93.3%) of 15 nerve transfers for the axillary nerve. Although, we found no significant statistical difference between analysed patients according to the percentage of recoveries and mean values, we established a better quality and shorter time of recovery for the musculocutaneous nerve. According to obtained results, we consider that transfer may be a valuable method in reconstruction after directly irreparable C5 and C6 spinal nerve lesions.

Adolescent↗
PubMed1998

Femoral nerve transfer for treatment of brachial plexus root avulsion.

Femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles was performed to determine its protective effect on the hand intrinsic muscles. Seven cases of brachial plexus root avulsion treated from May of 1989 to October of 1991 were involved. The femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles was done at the same stage of multiple neurotization. The muscular branches derived from the femoral nerve were isolated and coapted with the thenar muscle branch of the median nerve and the deep branch of the ulnar nerve. A groin flap was harvested simultaneously to form a skin-tube pedicle that covered the nerve bridge. At the second stage, when regeneration of the median and ulnar nerves was found to reach as far as the level of the wrist, the femoral nerve was divided and the muscular branches of the thenar and hypothenar muscles were anastomosed with the regenerated median and ulnar nerves. All the cases were followed up for more than 6 years. Six months after femoral nerve transfer, muscle power of the interosseous muscles and adductor pollicis recovered to MRC3, whereas that of the abductor pollicis brevis recovered to MRC1 to 2. Five cases underwent second-stage transfer. Four to five years of follow-up revealed that the muscle power of the interosseous muscles and adductor pollicis was MRC2 in one case, MRC1 in three cases, and MRC0 in one case. As for the donor area, muscle power of the quadriceps femoris reduced to M3 to 4 within 1 month after femoral nerve transfer and recovered to normal at 3 months. In conclusion, femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles has some protective effect on the hand intrinsic muscles. The outcome of the second stage, however, is not satisfactory.

Adolescent↗
PubMed1995

Intercostal nerve transfer to restore upper extremity functions after brachial plexus injury.

We report the efficacy of intercostal nerve transfer to restore elbow flexion, shoulder functions, and hand functions. One hundred and twelve patients with loss of elbow flexion were treated with intercostal nerve transfer to the musculocutaneous nerve and 97 (87%) of them regained grade 3 or 4 elbow flexion. Seven patients with loss of shoulder functions were treated with combined intercostal nerve transfer to the axillary nerve and phrenic nerve transfer to the suprascapular nerve, and 4 (57%) of them regained more than 80 degrees abduction and 5 (71%) regained more than 50 degrees external rotation starting with the forearm against the chest. To restore hand functions, intercostal nerves were sutured to the radial nerve or one of its branches in 40 patients and to the median nerve in 10 patients. Motor recovery was poor in both nerve transfers, but protective sensation was regained in the fingers innervated by the median nerve in 9 (90%) of the 10 patients. We conclude that intercostal nerve transfer after brachial plexus injury was a useful procedure to restore elbow flexion and shoulder functions, and for restoring a protective sensation in the fingers.

Adolescent↗
PubMed1992

[Experimental reconstruction on intrinsic hand muscle function by anterior interosseous nerve transference].

The anterior interosseous nerve was transferred to the recurrent branch of the median nerve and the deep branch of the ulnar nerve respectively to restore the function of the intrinsic hand muscles. Twelve Rhesus monkeys were used with 24 nerves for transference and 24 for direct suturing. Gross, histological, and ultrastructural observations, electrophysiological evaluation and computer-imaging analysis system were employed to assess the nerve regeneration process in 1,3,6, and 12 months after operation. The results showed that the rate of maturity and the number of regenerating nerves in the distal segment approached the normal level and the passing rate of the myelinated axons reached to 156.16 +/- 14.45% 12 months after operation. According to the histological findings and the recovery of the intrinsic hand muscle function, reinnervation in the transferred nerves occurred 1 to 3 months earlier than that in the directly sutured ones.

Animals↗
PubMed2004

Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve.

PURPOSE: In C5 and C6 brachial plexus avulsion lesions, elbow flexion, shoulder abduction, and external rotation are the functions that need to be restored. Because the proximal stumps are not available for grafting, surgical repair is based on nerve transfers. The purpose of this study was to describe and report the results of the use of multiple nerve transfers in the reconstruction of these avulsion injuries. METHODS: Ten patients had multiple nerve transfers: cranial nerve XI to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps long or lateral head motor branch to the axillary nerve. Triceps branch transfer was performed through a posterior arm incision. RESULTS: Two years after surgery, all the patients had recovered full elbow flexion; 7 scored M4 and 3 scored M3+ according to Medical Research Council scoring. All the patients had recovered active abduction and external rotation. Abduction recovery averaged 92 degrees (range, 65 degrees-120 degrees) and external rotation, measured from full internal rotation, averaged 93 degrees (range, 80 degrees-120 degrees). Shoulder abduction strength was graded M4 in 3 patients and M3 in the remaining 7 patients. Shoulder external rotation strength was graded M4 in 2 patients, M3 in 5 patients, and M2 in 3 patients. No donor site deficits were observed. CONCLUSIONS: The proposed nerve transfers constitute a valid strategy in C5-C6 avulsion injury reconstruction.

Accessory Nerve↗
PubMed2004

Phrenic nerve transfer in the treatment of brachial plexus avulsion: an experimental study of nerve regeneration and muscle morphology in rats.

The regeneration of motor and sensory neurons and the morphological changes of the target muscle after phrenic nerve transfer were investigated in adult rats. Six months following nerve transfer, 326.0 +/- 16.31 phrenic motoneurons regenerated into musculocutaneous nerve, which is not different from the normal number of phrenic motoneurons. The regenerated motoneurons exhibited a 14% nonsignificant hypertrophy. Of the dorsal root ganglia (DRG) neurons, 255.8 +/- 45.26 regenerated, which was significantly lower than the number of normal phrenic DRG neurons. The regenerated phrenic DRG neurons showed a 24% close-to-significant atrophy. The target muscle fiber morphology changed considerably after reinnervation. The present results suggest that the phrenic nerve has very good regenerative ability in terms of its motoneurons and a relatively insufficient sensory neuronal regeneration.

Animals↗
PubMed2001

Vascularized versus non-vascularized nerve transfers: histologic study in rats.

From the clinical point of view, the state of vascularized nerve transfers is clearly demonstrated in the literature. This study was carried out to elicit the basic histologic differences between vascularized and non-vascularized nerve transfers in an animal experiment. In 46 rats, the lateral femoral cutaneous nerve was resected, and an interposition with a free (n=23) ischiatic nerve transfer on one side and a vascularized (n=23) ischiatic nerve transfer on the other side was carried out. Three months postoperatively, the rats were sacrificed and 45 nerve transfers and 46 contralateral reference specimen probes were histologically evaluated. A lower degree of nerve fibrosis and vesicular degeneration of the myelin sheath were found in the vascularized nerve transfers, compared to the free non-vascularized transfers. The thickness of the myelin sheaths was less in the free transfers. From a histologic point of view, a lower degree of degenerative changes was seen in the vascularized nerves after transfer.

Animals↗
PubMed2004

Pulmonary and biceps function after intercostal and phrenic nerve transfer for brachial plexus injuries.

This pseudo-randomized study was performed to compare the pulmonary function and biceps recovery after intercostal (19 cases) and phrenic (17 cases) nerve transfer to the musculocutaneous nerve for brachial plexus injury patients with nerve root avulsions. Pulmonary function was assessed pre-operatively and postoperatively by measuring the forced vital capacity, forced expiratory volume in 1 second, vital capacity, and tidal volume. Motor recovery of biceps was serially recorded. Our results revealed that pulmonary function in the phrenic nerve transfer group was still significantly reduced 1 year after surgery. In the intercostal nerve transfer group, pulmonary function was normal after 3 months. Motor recovery of biceps in the intercostal nerve group was significantly earlier than that in phrenic nerve group. We conclude that pulmonary and biceps functions are better after intercostal nerve transfer than after phrenic nerve transfer in the short term at least.

Adolescent↗
PubMed2005

Comparative clinic study on vascularized and nonvascularized full-length phrenic nerve transfer.

In order to understand whether the vascularizing procedure has any clinical value in nerve transfer and grafting, we compared nonvascularized and vascularized full-length phrenic never transfers in patients with a brachial plexus injury. Full-length phrenic nerve transfer to the musculocutaneous nerve had been conducted by the technique of video-assisted thoracic surgery in 15 patients. Three kinds of procedures were carried out. The first involved retaining the initial point of the phrenic nerve and dissecting the full-length distal nerve. The second involved keeping the cervical segment and isolating the thoracic segment of the phrenic nerve. The last involved vascularized phrenic nerve transfer. All these phrenic nerves were sutured to musculocutaneous nerves. After 28-35 months, the results of electrophysiology and function of the biceps brachii muscle were compared. All three procedures had no significant differences and led to the same functional recovery of the biceps brachii muscle after at least 28 months of follow-up. In conclusion, the vascularizing procedure had little clinical value, not only in full-length phrenic nerve transfer, but also in nerve grafting irrespective of the length of the gap, when the recipient bed had normal vascularity.

Adult↗
PubMed2004

Nerve transfers for severe brachial plexus injuries: a review.

Nerve transfer procedures are increasingly performed for repair of severe brachial plexus injury (BPI), in which the proximal spinal nerve roots have been avulsed from the spinal cord. The procedure essentially involves the coaption of a proximal foreign nerve to the distal denervated nerve to reinnervate the latter by the donated axons. Cortical plasticity appears to play an important physiological role in the functional recovery of the reinnervated muscles. The author describes the general principles governing the successful use of nerve transfers. One major goal of this literature review is to provide a comprehensive survey on the numerous intra- and extraplexal nerves that have been used in transfer procedures to repair the brachial plexus. Thus, an emphasis on clinical outcomes is provided throughout. The second major goal is to discuss the role of candidate nerves for transfers in the surgical management of the common severe brachial plexus problems encountered clinically. It is hoped that this review will provide the treating surgeon with an updated list, indications, and expected outcomes involving nerve transfer operations for severe BPIs.

Accessory Nerve↗