Outcomes of Surgical Treatment of Brachial Plexus Injuries Using Nerve Grafting and Nerve Transfers

ABSTRACT

Between 1993 and 1998, 32 male patients with brachial plexus injuries were surgically treated. Eighteen interfascicular grafting and 71 extraplexal neurotization procedures were performed separately or in combination. Donor nerves were the intercostals, spinal accessory, phrenic, contralateral C7, and cervical plexus, in order of frequency. Patients were followed for a minimum of 24 (average, 35) months. Biceps function was best following grafting the musculocutaneous nerve itself, or neurotization with the phrenic nerve (100 percent grade 4), followed by neurotization with the intercostals (89.5 percent grade 3 or more) and last, grafting the C5 root or upper trunk (grade 3 in one of three patients). Phrenic to suprascapular neurotization produced the best results of shoulder abduction (40 to 90 degrees), followed by combined neurotization of the spinal accessory to suprascapular and phrenic to axillary (20 to 90 degrees). Sensory recovery over the lateral forearm and palm varied from S2 to S3+, according to the method of reconstruction.

KEYWORD

Brachial plexus - neurotization - phrenic nerve - intercostals - contralateral C7

REFERENCES

• 1 Millesi H. Brachial plexus injuries: nerve grafting.  Clin Orthop . 1988;  237 36
• 2 Taylor G I, Ham F J. The free vascularized nerve graft: a further experimental and clinical application of microvascular techniques.  Plast Reconstr Surg . 1976;  57 413
• 3 Birch R, Dunkerton M, Bonney G, Jamieson A M. Experience with free vascularized ulnar nerve graft in repair of supraclavicular lesions of the brachial plexus.  Clin Orthop . 1989;  237 96
• 4 Breidenbach W C, Terzis J K. Vascularized nerve grafts: an experimental and clinical review.  Ann Plast Surg . 1987;  18 137
• 5 Narakas A O. Neurotization in the treatment of brachial plexus injuries. In: Gelberman R (ed): Operative Nerve Repair and Reconstruction.Philadelphia: Lippincott Williams and Wilkins Company, 1991
• 6 Seddon L. Nerve grafting.  J Bone Joint Surg . 1966;  45-B 447
• 7 Kotani P T, Matsuda H, Suzuki T. Trial surgical procedures of nerve transfers to avulsion injuries of plexus brachialis.  Excerpta Med . 1972;  291 348
• 8 Tsuyama N, Hara T. Intercostal nerve crossing as a treatment of irreparably damaged whole brachial plexus. In: Nobel J, Galasko CSB (eds): Recent Developments in Orthopaedic Surgery Manchester: Manchester University Press 1988: 169
• 9 Allieu Y, Cenac P. Neurotization via the spinal accessory nerve in complete paralysis due to multiple avulsion injuries of the brachial plexus.  Clin Orthop . 1988;  237 67
• 10 Gu Y D, Ma M K. Use of the phrenic nerve for brachial plexus reconstruction.  Clin Orthop . 1996;  323 119
• 11 Gu Y D, Chen D S, Zhang G M. Long term functional results of contralateral C7 transfer.  J Reconstr Microsurg . 1998;  14 57
• 12 Birch R. Brachial plexus injuries.  J Bone Joint Surg . 1996;  79B 986
• 13 Chuang D C, Epstein M D, Yeh M C, Wei F C. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injuries).  J Hand Surg . 1993;  18A 285
• 14 Ihara K, Doi K, Sakai K. Restoration of sensibility in the hand after complete brachial plexus injury.  J Hand Surg . 1996;  21A 381
• 15 Bentolila V, Nizard R, Bizot P, Sedel L. Complete traumatic brachial plexus palsy: treatment and outcome after repair.  J Bone Joint Surg . 1999;  81A 20
• 16 Terzis J K, Marios D V, Soucacos P N. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis.  Plast Reconstr Surg . 1999;  104 1221
• 17 Nagano A, Yamamoto S, Mikami Y. Intercostal nerve transfer to restore upper extremity functions after brachial plexus injury.  Ann Acad Med Singapore . 1995;  24 42
• 18 Songcharoen P. Brachial plexus injury in Thailand: a report of 520 cases.  Microsurgery . 1995;  16 35
• 19 Songcharoen P, Mahaisavariya B, Chotigavanich C. Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus.  J Hand Surg . 1996;  21A 387
• 20 Berman J, Anand P, Chen L. Pain relief from preganglionic injury to the brachial plexus by late intercostal nerve transfer.  J Bone Joint Surg . 1996;  78B 759
• 21 Chuang D C, Lee G W, Hashem F, Wei F C. Restoration of shoulder abduction by nerve transfers in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers.  Plast Reconstr Surg . 1996;  96 122
• 22 Chuang D C. Contralateral C7 transfer (CC-7T) for avulsion injury of the brachial plexus.  Tech Hand Upper Extrem Surg . 1999;  3 185
• 23 Waikakul S, Orapin S, Vanadurongwan V. Clinical results of contralateral C7 root neurotization to the median nerve in brachial plexus injuries with total root avulsions.  J Hand Surg . 1999;  24B 556