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CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2018; 37(04): 285-290
DOI: 10.1055/s-0038-1676533
Original Article | Artigo Original
Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Restauração da flexão do cotovelo na paralisia traumática superior do plexo braquial em adultos: resultado com transferências intraplexuais distais em 78 pacientes
Mario G. Siqueira
1   Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Instituto de Psiquiatria, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
,
Roberto S. Martins
1   Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Instituto de Psiquiatria, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
,
Wilson Faglioni Junior
1   Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Instituto de Psiquiatria, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
,
Luciano Foroni
1   Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Instituto de Psiquiatria, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
,
Carlos Otto Heise
1   Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Instituto de Psiquiatria, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
2   Division of Clinical Neurophysiology, Department of Neurology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
› Institutsangaben
Weitere Informationen

Publikationsverlauf

14. September 2018

26. Oktober 2018

Publikationsdatum:
12. Dezember 2018 (online)

   Lizenzen und Reprints

Abstract

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury.

Method The files of 78 adult patients with C5, C6, ± C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n = 43), or a fascicle of the median nerve (group B, n = 16) or a combination of both (group C, n = 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result.

Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar + median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer.

Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Resumo

Objetivo Apresentar os resultados funcionais das técnicas de transferências de nervos para a restauração da flexão do cotovelo em lesões traumáticas superiores do plexo braquial.

Método Foram revisados os arquivos de 78 pacientes adultos com lesões de C5, C6, ± C7. Na tentativa de restaurar a flexão do cotovelo, foram realizadas transferência de nervos intraplexuais distais utilizando um fascículo do nervo ulnar (grupo A, n = 43), ou um fascículo do nervo mediano (grupo B, n = 16) ou uma combinação de ambos (grupo C, n = 19). Os resultados do tratamento com diferentes tipos de transferências de nervos foram definidos com base no sistema de graduação do British Medical Research Council: força muscular < M3 foi considerado como mau resultado.

Resultados A incidência global de bons/excelentes resultados com essas transferências de nervos foi de 80,7% e para as diferentes técnicas cirúrgicas (grupos A, B, C), foi de 86%, 56,2% e 100%, respectivamente. Pacientes submetidos à transferência do nervo ulnar ou à dupla transferência (transferência de fascículos ulnar + mediano) alcançaram melhor resultado que aqueles submetidos à transferência isolada de fascículo do nervo mediano (p < 0,05). Não houve diferença estatística significativa entre os resultados da transferência de fascículo do nervo ulnar e a transferência dupla.

Conclusão A transferência distal de nervos pode produzir resultados bons e excelentes na restauração da flexão do cotovelo em pacientes com lesão traumática do plexo braquial superior.

Keywords

brachial plexus palsy - distal nerve transfers - elbow flexion restoration

Palavras-chave

paralisia do plexo braquial - transferências distal de nervos - restauração da flexão do cotovelo
 

  • References

  • 1 Alnot JY, Rostoucher P, Oberlin C, Touam C. [C5-C6 and C5-C6-C7 traumatic paralysis of the brachial plexus of the adult caused by supraclavicular lesions]. Rev Chir Orthop Repar Appar Mot 1998; 84 (02) 113-123 (French)
    PubMedGoogle Scholar
  • 2 Millesi H, Meissl G, Katzer H. [Therapy of brachial plexus injuries. Proposal for an integrated therapy]. Bruns Beitr Klin Chir (1971) 1973; 220 (04) 429-446 (German)
    PubMedGoogle Scholar
  • 3 Narakas AO, Hentz VR. Neurotization in brachial plexus injuries. Indication and results. Clin Orthop Relat Res 1988; (237) 43-56
    PubMedGoogle Scholar
  • 4 Faglioni Jr W, Siqueira MG, Martins RS, Heise CO, Foroni L. The epidemiology of adult traumatic brachial plexus lesions in a large metropolis. Acta Neurochir (Wien) 2014; 156 (05) 1025-1028
    CrossrefPubMedGoogle Scholar
  • 5 Lusskin R, Campbell JB, Thompson WAL. Post-traumatic lesions of the brachial plexus: treatment by transclavicular exploration and neurolysis or autograft reconstruction. J Bone Joint Surg Am 1973; 55 (06) 1159-1176
    CrossrefPubMedGoogle Scholar
  • 6 Narakas A. [Indications and results of direct surgical treatment in lesions caused by stretching of the brachial plexus. I. Indications for direct surgical treatment]. Rev Chir Orthop Repar Appar Mot 1977; 63 (01) 88-106 [French]
    PubMedGoogle Scholar
  • 7 Bertelli JA, Ghizoni MF. Results of grafting the anterior and posterior divisions of the upper trunk in complete palsies of the brachial plexus. J Hand Surg Am 2008; 33 (09) 1529-1540
    CrossrefPubMedGoogle Scholar
  • 8 Bertelli JA, Ghizoni MF. Reconstruction of complete palsies of the adult brachial plexus by root grafting using long grafts and nerve transfers to target nerves. J Hand Surg Am 2010; 35 (10) 1640-1646
    CrossrefPubMedGoogle Scholar
  • 9 Birch R. Surgical Disorders of the Peripheral Nerves. 2nd edition. London: Springer; 2011
    Google Scholar
  • 10 Chuang DCC, Epstein MD, Yeh MC, Wei FC. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury). J Hand Surg Am 1993; 18 (02) 285-291
    PubMedGoogle Scholar
  • 11 Garg R, Merrell GA, Hillstrom HJ, Wolfe SW. Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis. J Bone Joint Surg Am 2011; 93 (09) 819-829
    CrossrefPubMedGoogle Scholar
  • 12 Hentz VR, Narakas A. The results of microneurosurgical reconstruction in complete brachial plexus palsy. Assessing outcome and predicting results. Orthop Clin North Am 1988; 19 (01) 107-114
    PubMedGoogle Scholar
  • 13 Kline DG, Hudson AR. Nerve Injuries. Operative results for major nerve injuries, entrapments, and tumors. Philadelphia: WB Saunders; 1995
    Google Scholar
  • 14 Lanaras TI, Schaller HE, Sinis N. Brachial plexus lesions: 10 years of experience in a center for microsurgery in Germany. Microsurgery 2009; 29 (02) 87-94
    CrossrefPubMedGoogle Scholar
  • 15 MacKinnon SE, Dellon AL. Surgery of the Peripheral Nerve. New York: Thieme; 1988
    Google Scholar
  • 16 Midha R. Stretch injuries to brachial plexus. In: Kim DH, Midha R, Murovic JA, Spinner RJ. , eds. Kline & Hudson's Nerve Injuries – Operative Results for Major Nerve Injuries, Entrapments, and Tumors, 2nd ed. Philadelphia: Saunders-Elsevier; 2008: 325-362
    Google Scholar
  • 17 Ochiai N, Nagano A, Sugioka H, Hara T. Nerve grafting in brachial plexus injuries. Results of free grafts in 90 patients. J Bone Joint Surg Br 1996; 78 (05) 754-758
    PubMedGoogle Scholar
  • 18 Socolovsky M, Martins RS, Di Masi G, Siqueira M. Upper brachial plexus injuries: grafts vs ulnar fascicle transfer to restore biceps muscle function. Neurosurgery 2012; 71 (2, Suppl Operative) ons227-ons232
    PubMedGoogle Scholar
  • 19 Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 2000; 106 (05) 1097-1122 , quiz 1123–1124
    CrossrefPubMedGoogle Scholar
  • 20 Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg 1999; 104 (05) 1221-1240
    CrossrefPubMedGoogle Scholar
  • 21 Tonkin MA, Eckersley JR, Gschwind CR. The surgical treatment of brachial plexus injuries. Aust N Z J Surg 1996; 66 (01) 29-33
    CrossrefPubMedGoogle Scholar
  • 22 Vekris MD, Soucacos PN. Post-traumatic brachial plexus paralysis: current management of reconstruction. Curr Orthop 2001; 15: 76-83
    CrossrefPubMedGoogle Scholar
  • 23 Ali ZS, Heuer GG, Faught RWF. , et al. Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques. J Neurosurg 2015; 122 (01) 195-201
    CrossrefPubMedGoogle Scholar
  • 24 Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. 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. J Hand Surg Am 1994; 19 (02) 232-237
    CrossrefPubMedGoogle Scholar
  • 25 Barthel PY, Barbary S, Breton A. , et al. [Recovery of elbow flexion in post-traumatic C5-C6 and C5-C6-C7 palsy: retrospective dual-center study comparing single and double nerve transfer]. Chir Main 2014; 33 (03) 211-218 [French]
    CrossrefPubMedGoogle Scholar
  • 26 Carlsen BT, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Comparison of single versus double nerve transfers for elbow flexion after brachial plexus injury. Plast Reconstr Surg 2011; 127 (01) 269-276
    CrossrefPubMedGoogle Scholar
  • 27 Cho AB, Paulos RG, de Resende MR. , et al. Median nerve fascicle transfer versus ulnar nerve fascicle transfer to the biceps motor branch in C5-C6 and C5-C7 brachial plexus injuries: nonrandomized prospective study of 23 consecutive patients. Microsurgery 2014; 34 (07) 511-515
    CrossrefPubMedGoogle Scholar
  • 28 Coulet B, Boretto JG, Lazerges C, Chammas M. A comparison of intercostal and partial ulnar nerve transfers in restoring elbow flexion following upper brachial plexus injury (C5-C6+/-C7). J Hand Surg Am 2010; 35 (08) 1297-1303
    CrossrefPubMedGoogle Scholar
  • 29 Ferraresi S, Garozzo D, Buffatti P. Reinnervation of the biceps in C5-7 brachial plexus avulsion injuries: results after distal bypass surgery. Neurosurg Focus 2004; 16 (05) E6
    PubMedGoogle Scholar
  • 30 Grondin RT, Durand S, Oberlin C. Fascicular nerve transfers to restore elbow flexion. In: Midha R, Zager ER. , eds. Surgery of Peripheral Nerves: A Case-Based Approach. New York: Thieme; 2008: 60-64
    Google Scholar
  • 31 Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Ketmalasiri W. Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg Am 1998; 23 (04) 711-716
    PubMedGoogle Scholar
  • 32 Loy S, Bhatia A, Asfazadourian H, Oberlin C. [Ulnar nerve fascicle transfer onto to the biceps muscle nerve in C5-C6 or C5-C6-C7 avulsions of the brachial plexus. Eighteen cases]. Ann Chir Main Memb Super 1997; 16 (04) 275-284 [French]
    PubMedGoogle Scholar
  • 33 Sedain G, Sharma MS, Sharma BS, Mahapatra AK. Outcome after delayed Oberlin transfer in brachial plexus injury. Neurosurgery 2011; 69 (04) 822-827 , discussion 827–828
    CrossrefPubMedGoogle Scholar
  • 34 Sungpet A, Suphachatwong C, Kawinwonggowit V, Patradul A. Transfer of a single fascicle from the ulnar nerve to the biceps muscle after avulsions of upper roots of the brachial plexus. J Hand Surg [Br] 2000; 25 (04) 325-328
    CrossrefPubMedGoogle Scholar
  • 35 Teboul F, Kakkar R, Ameur N, Beaulieu JY, Oberlin C. Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy. J Bone Joint Surg Am 2004; 86-A (07) 1485-1490
    PubMedGoogle Scholar
  • 36 Vekris MD, Beris AE, Johnson EO. , et al. Musculocutaneous neurotization to restore elbow flexion in brachial plexus paralysis. Microsurgery 2006; 26 (04) 325-329
    CrossrefPubMedGoogle Scholar
  • 37 Venkatramani H, Bhardwaj P, Faruquee SR, Sabapathy SR. Functional outcome of nerve transfer for restoration of shoulder and elbow function in upper brachial plexus injury. J Brachial Plex Peripher Nerve Inj 2008; 3: 15
    PubMedGoogle Scholar
  • 38 Hou Z, Xu Z. Nerve transfer for treatment of brachial plexus injury: comparison study between the transfer of partial median and ulnar nerves and that of phrenic and spinal accessary nerves. Chin J Traumatol 2002; 5 (05) 263-266
    PubMedGoogle Scholar
  • 39 Sungpet A, Suphachatwong C, Kawinwonggowit V. One-fascicle median nerve transfer to biceps muscle in C5 and C6 root avulsions of brachial plexus injury. Microsurgery 2003; 23 (01) 10-13
    CrossrefPubMedGoogle Scholar
  • 40 Nath RK, Lyons AB, Bietz G. Physiological and clinical advantages of median nerve fascicle transfer to the musculocutaneous nerve following brachial plexus root avulsion injury. J Neurosurg 2006; 105 (06) 830-834
    CrossrefPubMedGoogle Scholar
  • 41 Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 2003; 98 (02) 313-318
    CrossrefPubMedGoogle Scholar
  • 42 Bhandari PS, Sadhotra LP, Bhargava P. , et al. Surgical outcomes following nerve transfers in upper brachial plexus injuries. Indian J Plast Surg 2009; 42 (02) 150-160
    CrossrefPubMedGoogle Scholar
  • 43 Liverneaux PA, Diaz LC, Beaulieu JY, Durand S, Oberlin C. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstr Surg 2006; 117 (03) 915-919
    CrossrefPubMedGoogle Scholar
  • 44 Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am 2005; 30 (05) 978-985
    CrossrefPubMedGoogle Scholar
  • 45 Ray WZ, Pet MA, Yee A, Mackinnon SE. Double fascicular nerve transfer to the biceps and brachialis muscles after brachial plexus injury: clinical outcomes in a series of 29 cases. J Neurosurg 2011; 114 (06) 1520-1528
    CrossrefPubMedGoogle Scholar
  • 46 Martins RS, Siqueira MG, Heise CO, Foroni L, Teixeira MJ. A prospective study comparing single and double fascicular transfer to restore elbow flexion after brachial plexus injury. Neurosurgery 2013; 72 (05) 709-714 , discussion 714–715, quiz 715
    CrossrefPubMedGoogle Scholar
  • 47 Malessy MJ, Bakker D, Dekker AJ, Van Duk JG, Thomeer RT. Functional magnetic resonance imaging and control over the biceps muscle after intercostal-musculocutaneous nerve transfer. J Neurosurg 2003; 98 (02) 261-268
    CrossrefPubMedGoogle Scholar
  • 48 Malessy MJ, Thomeer RT, van Dijk JG. Changing central nervous system control following intercostal nerve transfer. J Neurosurg 1998; 89 (04) 568-574
    CrossrefPubMedGoogle Scholar