Background: In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries.

Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05.

Results: Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve.

Conclusions: In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

/pdf/comparison-of-nerve-transfers-and-nerve-grafting-for-6j3xsozd36.pdf

Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis.

Background:Nerve transfer surgery has revolutionized the management of traumatic brachial plexus injures However, the optimal size ratio of donor to recipient nerve has yet to be elucidated The authors investigated the axon count ratios of ulnar and median fascicular transfers to restore elbow fle

Optimal axon counts for brachial plexus nerve transfers to restore elbow flexion.

Object The clinical outcomes of patients with brachial plexus injuries who underwent double fascicular transfer (DFT) using fascicles from the median and ulnar nerves to reinnervate the biceps and brachialis muscles were evaluated. Methods The authors conducted a retrospective chart review of 29 patients with brachial plexus injuries that were treated with DFT for restoration of elbow flexion. All patients underwent pre- and postoperative clinical evaluation using the Medical Research Council grading system. Results The mean patient age was 37 years (range 17–68 years), and there was a mean follow-up of 19 ± 12 months (range 8–68 months). At the most recent follow-up, all but 1 patient (97%) had regained elbow flexion. Eight patients recovered Grade M5, 15 patients recovered Grade M4, and 4 patients recovered Grade M3 elbow flexion strength. There was no evidence of functional deficit in the donor nerve distributions. Conclusions Study results demonstrated the reliable restoration of M4–M5 elbow flexion f...

Double fascicular nerve transfer to the biceps and brachialis muscles after brachial plexus injury: clinical outcomes in a series of 29 cases.

OBJECT Adult upper trunk brachial plexus injuries result in significant disability. Several surgical treatment strategies exist, including nerve grafting, nerve transfers, and a combination of both approaches. However, no existing data clearly indicate the most successful strategy for restoring elbow flexion and shoulder abduction in these patients. The authors reviewed the literature to compare outcomes of the three surgical repair techniques listed above to determine the optimal approach to traumatic injury to the upper brachial plexus in adults. METHODS Both PubMed and EMBASE databases were searched for English-language articles containing the MeSH topic “brachial plexus” in conjunction with the word “injury” or “trauma” in the title and “surgery” or “repair” as a MeSH subheading or in the title, excluding pediatric articles and those articles limited to avulsions. The search was also limited to articles published after 1990 and containing at least 10 operated cases involving upper brachial plexus inju...

/pdf/upper-brachial-plexus-injury-in-adults-comparative-4510ijbfne.pdf

Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques

To examine the clinical effectiveness and safety of phrenic nerve neurotization for brachial plexus reconstruction, the authors retrospectively analyzed the surgically treated cases within the period between August 1970 and March 1990. There was a total of 180 patients who sustained brachial plexus injuries and had phrenic nerve transfer. The phrenic nerve was identified and traced distally to give the longest possible length and sectioned. The proximal stump was coapted to the distal segment of the musculocutaneous nerve, either directly or through a nerve graft. Sixty-five patients who were seen in followup for >2 years were studied. The time taken for the return of a muscle power rating of 3 (M3) in the biceps muscle ranged from 3 to 30 months ; the average time was 9.5 months. Of the patients, 84.6% regained biceps power to M3 and greater strength. Only 1 patient had a transient respiratory problem after surgery. Pulmonary function tests showed decreased pulmonary capacities within 1 year of operation, improving toward 2 years. Thus, it is concluded that phrenic nerve neurotization can be accepted as a sound option for the restoration of biceps function in brachial plexus injury.

Use of the phrenic nerve for brachial plexus reconstruction : How the east meets the west : Unique orthopaedic problems in Asia-pacific region

Background: Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury. Materials and Methods: We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient). Results: Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).

Surgical outcomes following nerve transfers in upper brachial plexus injuries.

What is new in peripheral nerve repair

Multiple nerve transfers for the reanimation of shoulder and elbow functions in irreparable C5, C6 and upper truncal lesions of the brachial plexus

Management of missile injuries of the brachial plexus

Dorsal approach in spinal accessory to suprascapular nerve transfer in brachial plexus injuries: technique details

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