Neurotization for Shoulder Reanimation in Post-Traumatic Brachial Plexus Paralysis: Preliminary Results

In brachial plexus palsy patients, the reanimation of the shoulder is one of the primary goals in the reconstruction of the injured plexus. The authors presented their preliminary findings in shoulder reanimation.

During the last 6.5 years (March 1998 to October 2004), 63 adult patients with post-traumatic brachial plexus palsy were operated on. The mean patient age was 24.6 years and the most common cause of injury was a motor vehicle accident. Exploration of the brachial plexus was performed in 51 patients, while 12 were late cases (> 2 years) and only secondary procedures were done, i.e muscle transfers. The mean denervation time was 6 months (1 to 14 months). Nine patients had an extended infraclavicular lesion, while in the 42 supraclavicular lesions, 35 had an element of avulsion (7 global, 19 with four-root avulsion, and 9 with three roots avulsed). Neurotization of the suprascapular nerve was performed in the majority of cases directly from the terminal branch of the accessory nerve (32 patients) or via nerve grafts from intraplexus donors (C5) in 7 patients, while in 3 patients, cervical plexus motor donors were used. For the reconstruction of the axillary nerve in most cases (12), C5 was used via nerve grafts (2) – the phrenic in 4 patients, the cervical plexus motor donors in 2 cases, in 5 patients one graft from C5 and one graft from the phrenic or a cervical plexus motor donor, and finally in 3 patients, two intercostals were connected directly to the axillary nerve.

Intraplexus motor donors were far more superior for neurotizations ( M3 + and more for suprascapular neurotization in 80% of the patients and for axillary neurotization in 65% of the patients). All the patients with suprascapular neurotization via the accessory nerve regained useful function of the supraspinatus (M3 + to M4 + ) but not function of the infraspinatus. Combined neurotization of the suprascapular and axillary gave the best outcome for shoulder abduction (> 60 degrees) and if the teres minor branch was neurotized, external rotation was achieved as well.

In brachial plexus paralysis, when the element of avulsion is present, reconstruction often is based on the extraplexus donors. The return of shoulder function is greater and faster when intraplexus donors are used. Some extraplexus neurotizations, e.g., accessory to suparascapular, yield comparable results, while combined neurotization of the suprascapular and axillary offers better overall shoulder function.