The Effect of Age and the Delay before Surgery on the Outcomes of Intercostal Nerve Transfers to the Musculocutaneous Nerve: A Retrospective Study of 232 Cases of Posttraumatic Total and Near-total Brachial Plexus Injuries
Introduction Posttraumatic brachial plexus injuries are devastating, as the brain and spinal cord are disconnected from the upper limb. Restoration of elbow flexion has been widely recognized as the primary objective of nerve reconstruction. In the absence of utilizable (ruptured) root stumps in the neck, one has recourse only to nerve transfers. The direct transfer of intercostal nerves to the musculocutaneous nerve is one of the techniques that has been commonly employed over the past four decades. However, the outcomes of this procedure cited in the literature have varied considerably. The patient’s age and the delay from the accident to surgery have been known to affect the results of nerve reconstruction operations. The authors present a study of the effect of these parameters on intercostal nerve transfers.
Methods The data of 232 patients with total and near-total brachial plexus injuries treated by the senior author between April 1995 and December 2015 was examined. Intercostal nerve transfers were used for the restoration of biceps function in each of these patients. The outcomes were tabulated, and the correlation with the age and the delay before surgery was examined.
Results The strength of the biceps regained was better in patients younger than 30 years old and those operated upon earlier than 6 months from the accident. The differences in outcomes were found to be statistically significant (p = 0.001 for preoperative delay and p < 0.005 for the patient’s age).
Conclusion The results give clear proof of the significant effect of the age and preoperative delay on the outcomes of intercostal nerve transfers for restoration of biceps function. These findings can serve as pointers to help the surgeon in choosing the method of nerve reconstruction in a given case.
Keywordsbrachial plexus injury - elbow flexion reconstruction - intercostal nerve transfer - preoperative delay
30 August 2020 (online)
Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India
- 1 Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg 2005; 13 (06) 382-396
- 2 Brophy RH, Wolfe SW. Planning brachial plexus surgery: treatment options and priorities. Hand Clin 2005; 21 (01) 47-54
- 3 Sulaiman OA, Kim DD, Burkett C, Kline DG. Nerve transfer surgery for adult brachial plexus injury: a 10-year experience at Louisiana State University. Neurosurgery 2009; 65 (Suppl. 04) A55-A62
- 4 Gu YD, Zhang GM, Chen DS. et al. Cervical nerve root transfer from contralateral normal side for treatment of brachial plexus root avulsions. Chin Med J (Engl) 1991; 104 (03) 208-211
- 5 Waikakul S, Wongtragul S, Vanadurongwan V. Restoration of elbow flexion in brachial plexus avulsion injury: comparing spinal accessory nerve transfer with intercostal nerve transfer. J Hand Surg Am 1999; 24 (03) 571-577
- 6 Liu Y, Lao J, Zhao X. Comparative study of phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury. Injury 2015; 46 (04) 671-675
- 7 Seddon HJ. Nerve grafting. J Bone Joint Surg Br 1963; 45: 447-461
- 8 Narakas A. Surgical treatment of traction injuries of the brachial plexus. Clin Orthop Relat Res 1978; ( (133) 71-90
- 9 Tsuyama N, Hara T. Intercostal nerve transfer in the treatment of brachial plexus injury of root avulsion type. Exerpta Medica 1972; 29 (01) 35
- 10 Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg Am 2001; 26 (02) 303-314
- 11 Chuang DC, Yeh MC, Wei FC. Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients. J Hand Surg Am 1992; 17 (05) 822-828
- 12 Nagano A, Tsuyama N, Ochiai N, Hara T, Takahashi M. Direct nerve crossing with the intercostal nerve to treat avulsion injuries of the brachial plexus. J Hand Surg Am 1989; 14 (06) 980-985
- 13 Samardzić M, Rasulić L, Grujicić D, Milicić B. Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 2000; 46 (01) 93-101, discussion 101–103 [discussion: 101–3]
- 14 Bhatia A, Shyam AK, Doshi P, Shah V. Nerve reconstruction: A cohort study of 93 cases of global brachial plexus palsy. Indian J Orthop 2011; 45 (02) 153-160
- 15 Moiyadi AV, Devi BI, Nair KP. Brachial plexus injuries: outcome following neurotization with intercostal nerve. J Neurosurg 2007; 107 (02) 308-313
- 16 Terzis JK, Barbitsioti A. Primary restoration of elbow flexion in adult post-traumatic plexopathy patients. J Plast Reconstr Aesthet Surg 2012; 65 (01) 72-84
- 17 El-Gammal TA, Fathi NA. Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfers. J Reconstr Microsurg 2002; 18 (01) 7-15
- 18 Jivan S, Kumar N, Wiberg M, Kay S. The influence of pre-surgical delay on functional outcome after reconstruction of brachial plexus injuries. J Plast Reconstr Aesthet Surg 2009; 62 (04) 472-479
- 19 Ruch DS, Friedman A, Nunley JA. The restoration of elbow flexion with intercostal nerve transfers. Clin Orthop Relat Res 1995; (314) 95-103
- 20 Xiao C, Lao J, Wang T, Zhao X, Liu J, Gu Y. Intercostal nerve transfer to neurotize the musculocutaneous nerve after traumatic brachial plexus avulsion: a comparison of two, three, and four nerve transfers. J Reconstr Microsurg 2014; 30 (05) 297-304
- 21 Socolovsky M, di Masi G, Bonilla G, Lovaglio AC, López D. Age as a predictor of long term results in patients with brachial plexus palsies undergoing surgical repair. Oper Neurosurg (Hagerstown) 2018; 15 (01) 15-24