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PubMed1990

Phrenic nerve transfer for treatment of root avulsion of the brachial plexus.

Phrenic nerve transfer was performed in 164 patients with root avulsion of the brachial plexus. The methods of operation consisted of phrenic nerve transfer to and anastomosis with the musculocutaneous nerve, the phrenic nerve bridging to the musculocutaneous nerve, phrenic nerve anastomosis with or bridging to the median nerve, and phrenic nerve anastomosis with other nerves. Follow-up of 65 patients for more than 2 years showed an effective rate of 84.6%. The result indicated that this operation has no deleterious effects on respiration, and the surgical effects are related to severity of injury, duration, mode of operation and patient's age.

Adolescent↗
PubMed1992

[An experimental study of the treatment of root avulsion of brachial plexus using contralateral C7 nerve neurotization (nerve transfer)].

This study compared the functional results of contralateral C7 root neurotization with homolateral phrenic nerve transfer for repairing root avulsion of brachial plexus in rats. It was found that in the C7 nerve root group all the parameters of evoked muscle potential amplitude (EMPA), regenerating axon count, biceps weight and muscle fibre area, and muscular maximal tetanus tension were statistically superior (P < 0.05-0.01) to those in the phrenic nerve group; while there were no significant differences between these two groups in motor nerve latency regenerating axon area and persisting time of muscular maximal tetanus tension (P > 0.05). The reasons why C7 root neurotization is superior to phrenic nerve transfer were also discussed.

Animals↗
PubMed1999

Hypoglossal nerve transfer for laryngeal reinnervation: a preliminary study.

The hypoglossal nerve is a logical donor nerve for hemilaryngeal reinnervation because 1) its activity coincides with normal laryngeal adduction during speech and deglutition; 2) it is a large nerve with many axons; and 3) donor site morbidity is low. This method of laryngeal reinnervation has not been previously reported. Previous studies using the ansa cervicalis for reinnervation have failed to show spontaneous activity. Hypoglossal-to-recurrent laryngeal nerve anastomosis was performed on a series of 5 dogs. The vocal folds were viewed monthly, with the animals awake, by infraglottic examination through a permanent tracheostomy. One dog failed due to technical error. The remaining 4 dogs began to exhibit spontaneous vocal fold adduction within 2 to 4 months. Vocal fold motion was synchronous with spontaneous tongue motion. Complete glottic closure was seen during swallowing at 3 to 5 months. Intraglottic pressure measurements following reinnervation were normal. Hypoglossal nerve transfer appears to be capable of providing functional adduction to the paralyzed hemilarynx. The potential advantages and disadvantages of this new technique are discussed.

Anastomosis, Surgical↗
PubMed2006

Electromyographic comparison of various exercises to improve elbow flexion following intercostal nerve transfer.

We compared the quantitative electromyographic activity of the elbow flexors during four exercises (forced inspiration, forced expiration, trunk flexion and attempted elbow flexion), following intercostal nerve transfer to the musculocutaneous nerve in 32 patients who had sustained root avulsion brachial plexus injuries. Quantitative electromyographic evaluation of the mean and maximum amplitude was repeated three times for each exercise. We found that mean and maximum elbow flexor activity was highest during trunk flexion, followed by attempted elbow flexion, forced inspiration and finally forced expiration. The difference between each group was significant (p < 0.001), with the exception of the difference between trunk flexion and attempted elbow flexion. Consequently, we recommend trunk flexion exercises to aid rehabilitation following intercostal nerve transfer.

Adolescent↗
PubMed2005

Ventilation and exercise performance after phrenic nerve and multiple intercostal nerve transfers for avulsed brachial plexus injury.

BACKGROUND: Diaphragmatic excursion, lung function, exercise performance, and clinical symptoms have not been previously described in patients after phrenic nerve transfer (PNT) and/or multiple intercostal nerve transfer (MIT) for the repair of avulsed brachial plexus injury (ABPI) to prevent functional musculoskeletal impairment in the shoulder. SETTING: A university-based hospital. METHODS: Dyspnea scores, chest ultrasonography to assess diaphragmatic excursion, and pulmonary function testing were performed to assess ventilation in patients sustaining trauma to their brachial plexus. In addition, cardiopulmonary exercise testing was also performed. These studies were obtained prior to surgical intervention, and were repeated postoperatively at 6, 12, 18, 24, and 36 months. The results obtained preoperatively were compared to those obtained throughout the postoperative monitoring period. RESULTS: This study demonstrates that the PNT-MIT procedure results in permanent ipsilateral diaphragmatic paralysis accompanied by an approximately 8% decrease in inspiratory capacity, FVC, and total lung capacity. There was also an 11% increase in diffusing capacity noted during the period between 6 months and 3 years after PNT-MIT procedure. Despite these measurable changes in lung function, the patients reported amelioration of their dyspnea complaint within 6 months of undergoing this procedure, which was due mainly to an improvement in their cardiovascular exercise performance related to increased daily activity. CONCLUSIONS: This study demonstrates that the PNT-MIT procedure is a safe method for the restoration of drop shoulder incurred by ABPI. This surgery has an impact on measurable diaphragmatic and lung function but with minimal impact in terms of postoperative clinical symptoms and exercise performance.

Adult↗
PubMed1998

Experimental study of phrenic nerve transfer for treatment of brachial plexus root avulsion.

OBJECTIVE: To investigate the effects of neurorrhaphy, nerve grafting and nerve implantation in phrenic nerve transfer for treatment of brachial plexus root avulsion. METHODS: One hundred and eighty Sprague-Dawley rats were divided into three groups: the neurorrhaphy group, the nerve grafting group and the nerve implantation group. Evaluations such as motor nerve latency, amplitude of compound actional potentials, muscle weight, cross sectional areas of muscle fibers and myelinated axons, and muscle function were performed at 1, 2, 3, 4, 5 and 6 months postoperatively. All data were analyzed by the Student-Newman Keuls test in SAS software. RESULTS: Variable recovery in each group was found at different postoperative intervals. At six months after operation, the following results were observed in descending superiority: neurorrhaphy > nerve grafting > nerve implantation. Nerve implantation demonstrated the function recovery was 75.76%. CONCLUSIONS: This study demonstrates that neurorrhaphy is statistically superior to nerve grafting and nerve grafting superior to nerve implantation, and also confirms the validity of phrenic nerve implantation. But when no reparable distal nerve stump is available, nerve implantation is an effective method in phrenic nerve transfer for brachial plexus root avulsion to some extent.

Journal Article↗
PubMed2002

Patient outcome following a thoracodorsal to musculocutaneous nerve transfer for reconstruction of elbow flexion.

This study reports patient outcome following a thoracodorsal to musculocutaneous nerve transfer. We retrospectively reviewed the charts of six patients who had undergone transfer of the thoracodorsal nerve to the musculocutaneous nerve for reconstruction of elbow flexion. The mean age was 47 years (standard deviation: 24 years; range: 17-72 years). The mean time from injury to surgery was 3 months (standard deviation: 2 months; range: 1-5 months). In all cases, the biceps muscle was successfully reinnervated; in one case the Medical Research Council (MRC) muscle grade was grade 5, in four cases it was grade 4, and in one case it was grade 2. No patients complained of functional weakness with shoulder adduction and/or internal rotation. In the majority of cases, transfer of the thoracodorsal nerve to the musculocutaneous nerve provides excellent recovery of elbow flexion.

Adolescent↗
PubMed2006

Accessory nerve to suprascapular nerve transfer to restore shoulder exorotation in otherwise spontaneously recovered obstetric brachial plexus lesions.

OBJECTIVE: A systematic follow-up of infants with an obstetric brachial plexus lesion of C5 and C6 or the superior trunk showing satisfactory spontaneous recovery of shoulder and arm function except for voluntary shoulder exorotation, who underwent an accessory to suprascapular nerve transfer to improve active shoulder exorotation, to evaluate for functional recovery, and to understand why other superior trunk functions spontaneously recover in contrast with exorotation. METHODS: In 54 children, an accessory to suprascapular nerve transfer was performed as a separate procedure at a mean age of 21.7 months. Follow-up examinations were conducted before and at 4, 8, 12, 24, and 36 months after operation and included scoring of shoulder exorotation and abduction. Intraoperative reactivity of spinatus muscles and additional needle electromyographic responses were registered after electrostimulation of suprascapular nerves. Histological examination of suprascapular nerves was performed. Trophy of spinatus muscles was followed by magnetic resonance imaging scanning. The influence of perinatal variables and results of ancillary investigations on outcome were evaluated. RESULTS: Exorotation improved from 70 degrees to functional levels exceeding 0 degrees, except in two patients. Abduction improved in 27 patients, with results of 90 degrees or more in 49 patients. Electromyography at 4 months did not show signs of denervation in 39 out of 40 patients. Intraoperative electrostimulation of suprascapular nerves elicited spinatus muscle reaction in 44 out of 48 patients. Histology of suprascapular nerves was normal. Preoperative magnetic resonance imaging scans showed only minor wasting of spinatus muscles in contrast with major wasting after successful operations. CONCLUSION: An accessory to suprascapular nerve transfer is effective to restore active exorotation when performed as the primary or a separate secondary procedure in children older than 10 months of age. Contradictory spontaneous recovery of other superior trunk functions and integrity of suprascapular nerves, as well as absence of spinatus muscle wasting direct to central nervous changes are possible main causes for the lack of exorotation.

Accessory Nerve↗
PubMed2003

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

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.

Adolescent↗
PubMed2001

Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases.

A prospective study was conducted to evaluate patient outcomes following sensory nerve transfer. Twenty patients with irreparable ulnar or median nerve lesions underwent the procedure. Nerve involvement was bilateral in 5 cases. The mean age of the patients at the time of surgery was 29 years. The mean paralysis time and the average length of follow-up were 59 and 78 months, respectively. Eighteen of 20 patients attended a sensory re-education program after surgery. Outcome was assessed objectively by functional sensory recovery testing and by the British Medical Research Council standards. Subjective outcome was assessed by a questionnaire. Two-point discrimination of less than 10 mm was achieved in 15 of 25 hands. The mean functional sensory recovery score was 83. Eighteen of 20 patients reported that the function of their hands improved after the procedure. Good or excellent results were associated with immediate transfer of the nerve, young age, and patients' attendance to the sensory re-education program after surgery. No differences were found between the recovery of ulnar and median nerves. Based on these results we suggest that sensory nerve transfer is a simple and reliable way of restoring sensibility to the hand with favorably comparable results over conventional nerve grafting in selected cases.

Adolescent↗
PubMed2005

Direct plexus repair by grafts supplemented by nerve transfers.

This article reviews the Louisiana State University Health Sciences Center experience with direct repair of brachial plexus lacerations, gunshot wounds, and stretch/contusive/avulsive injuries. In the stretch category, limited outcomes with direct repair have led to addition of nerve transfers rather than their exclusive use. It is important to per-form direct plexus repair in conjunction with nerve transfers in the same patient when-ever possible. The intent of such a "pants-over-vest" approach is to maximize axonal input to denervated structures.

Brachial Plexus↗
PubMed1977

Experimental sensory reinnervation of the median nerve by nerve transfer in monkeys.

Anastomosis of the superficial radial nerve, the dorsal cutaneous branch of the ulnar nerve, or both to the distal cut end of a widely resected median nerve in monkeys was followed by successful sensory reinnervation of the thumb, index finger, and long finger within thiry-five to forty weeks. Success was ascertained by the presence of an intact anastomosis as observed grossly without any evidence of spontaneous regeneration of the median nerve. Reinnervation was confirmed by histological and histochemical reactions observed in the Meissner's corpuscles in the skin innervated by the median nerve. The demonstration of nerve fiber and the presence of normal specific and non-specific cholinesterase reactions exhibited by the Meissner's corpuscles in the cholinesterase preparations were considered the histological criteria for successful reinnervation. These histological and histochemical observations may explain the reported functional sensory recovery in clinical cases when similar nerve transfers were done.

Animals↗
PubMed1989

Blood-nerve transfer of albumin and its implications for the endoneurial microenvironment.

Blood-nerve transfer of plasma albumin was studied by measuring the permeability coefficient-surface area (PS) product of the blood-nerve barrier (BNB) to 125I-albumin in rat sciatic nerve using the i.v. bolus injection method. The calculated PS was 6.3 +/- 0.5 (S.E.M.) x 10(-7) ml.g-1.s-1. This value is smaller by more than an order of magnitude of that measured for sucrose and confirms the relative impermeance of the BNB to blood-borne solutes. From a review of the available evidence, it is concluded that normal blood-nerve exchange occurs predominantly across the endoneurial microvasculature, and the PS of the BNB reflects the permeability of capillaries to a greater extent than that of the perineurium. The only capillaries found to be less permeable than these are the cerebral capillaries. Proximo-distal differences (sciatic vs tibial) of the PS could not be detected. Blood-nerve albumin transfer was calculated at 1.2 mg.g-1.day-1, and the daily turnover of endoneurial albumin to be about 30%. It is postulated that small increases in PS of BNB to albumin lead to an elevation of endoneurial albumin concentration and, through the operation of Starling forces, subsequently produce endoneurial oedema. A major question posed by the results of this study is the identity of pathways for clearance of albumin and other macromolecules from the endoneurium.

Animals↗
PubMed2003

Brachial plexus injury: factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion.

OBJECT: Between 1994 and 1998, 44 nerve transfers were performed using a graft between a branch of the accessory nerve and musculocutaneous nerve to restore the flexion of the arm in patients with traumatic brachial plexus injuries. A retrospective study was conducted, including statistical evaluation of the following pre- and intraoperative parameters in 39 patients: 1) time interval between injury and surgery; and 2) length of the nerve graft used to connect the accessory and musculocutaneous nerves. METHODS: The postoperative follow-up interval ranged from 23 to 84 months, with a mean +/- standard deviation of 36 +/- 13 months. Reinnervation of the biceps muscle was achieved in 72% of the patients. Reinnervation of the musculocutaneous nerve was demonstrated in 86% of the patients who had undergone surgery within the first 6 months after injury, in 65% of the patients who had undergone surgery between 7 and 12 months after injury, and in only 50% of the patients who had undergone surgery 12 months after injury. A statistical comparison of the different preoperative time intervals (0-6 months compared with 7-12 months) showed a significantly better outcome in patients treated with early surgery (p < 0.05). An analysis of the impact of the length of the interposed nerve grafts revealed a statistically significant better outcome in patients with grafts 12 cm or shorter compared with that in patients with grafts longer than 12 cm (p < 0.005). CONCLUSIONS: Together, these results demonstrated that outcome in patients who undergo accessory to musculocutaneous nerve neurotization for restoration of elbow flexion following brachial plexus injury is greatly dependent on the time interval between trauma and surgery and on the length of the nerve graft used.

Accessory Nerve↗
PubMed2005

[Repairing brachial plexus root avulsion by nerve transfer].

OBJECTIVE: To summarize the experience of surgical treatment of brachial plexus root avulsion and to discuss the operations for different of types brachial plexus root avulsion. METHODS: We enrolled 18 cases of brachial plexus root avulsion with different surgical treatment by nerve transfer from October, 1998 to September, 2002. The follow-up time between 2 years 2 months to 5 years 8 months, the mean time being 3 years 10 months. RESULTS: The 18 patients were followed up more than 2 years. Of the 16 patients who lost shoulder abduction 11 had recovered to more than grade 3 strength of supraspinatus muscle; 4 had recovered to more than grade 3 strength of deltoid muscle. Of the 16 patients who lost elbow flexor function 14 had recovered to more than grade 3 strength of biceps muscle. Of the 6 patients who lost wrist and finger flexion, 2 had recovered to more than grade 3 strength in flexion of wrist and fingers. Of the 4 patients who lost radial nerve function, 3 had recovered to more than grade 3 strength of extend elbow and finger. All of them had recovered grade 3 strength of extend wrist. CONCLUSION: Accurate diagnosis, early operation and refine manipulation are key factors for functional recovery in transferring nerve treatment for brachial plexus root avulsion. Different methods should be selected according to the types of brachial plexus avulsion. All injured nerves should be repaired for young patients.

Adolescent↗
PubMed1999

Cross-chest radial nerve transfer in brachial plexus injuries. Experimental and anatomical basis.

Brachial plexus avulsion injuries are devastating injuries to the upper limb, and nerve transfer remains the only option in reconstruction. Despite the encouraging results concerning recovery of shoulder and elbow function, no option is available for treatment of the paralytic hand. In rats, we sectioned the radial nerve in the elbow region and transferred it across the chest to reinnervate the lesioned contralateral medial cord of the brachial plexus. Rats were then evaluated for motor and sensory recovery, electrophysiologically, behaviorally and morphologically. Forepaw functional recovery was estimated to be 90%. In cadavers, the radial nerve and profunda brachii artery were dissected. It was observed that the radial nerve vascularized by the profunda brachii artery was able to reach the contralateral brachial plexus distal to the shoulder region without nerve grafts. After sectioning the radial nerve, sensory loss is minimal and motor palsy can be easily restored by tendon transfers. The results of tendon transfer for radial nerve palsy are better than for any other nerve. Cross-chest radial nerve transfer might be of clinical interest in the reconstruction of hand function in entire injury to the brachial plexus.

Analysis of Variance↗
PubMed1994

Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases.

Four patients with C5-C6 root avulsion after brachial plexus injury were treated with a transfer of part of a normal functioning nerve in the arm to the motor nerve of the biceps. Ten percent of the bulk of the ulnar nerve was harvested for a suture directly to the motor nerve of the biceps with no significant impairment of hand function.

Adolescent↗