From 1986 to 1994, 82 patients with brachial plexus root avulsion were operated on using a contralateral C7 nerve-root transfer. Forty-four patients underwent a one-stage procedure in which the distal end of the ulnar nerve was anastomosed to the contralateral C7 root, and the other 38 underwent a two-stage procedure (first phase: C7 root --> ulnar nerve; second phase: ulnar nerve --> recipient nerve). Twenty postoperative cases were followed-up for 2 years. Of them, the ulnar nerve was transferred to the musculocutaneous nerve in six cases, with recovery of the biceps up to M3 in four and S3 in five cases; the ulnar nerve was transferred to the median nerve in eight cases, with recovery of the wrist and finger flexors up to M3 in five and S3 in six cases; the ulnar nerve was transferred to the radial nerve in four cases, with recovery of the triceps up to M4 in two and S3 in three cases; and the ulnar nerve was transferred to the thoracodorsal nerve in two cases, with recovery of the latissimus dorsi to M4 in one case. The total muscle recovery rate (up to M3) of the series was 60 percent, and the sensory recovery rate (S3) was 78 percent. Outcomes were related to patient age, operative delay, and whether or not the ulnar nerve was used as a bridge for transfer.

Mallet's test was used to evaluate shoulder and elbow functional results following conservative treatment, neurolysis, and nerve transfer and grafting in 31 patients with obstetrical brachial plexus palsy, who had no recovery of biceps contraction by 3 months of age. Twelve of them had been treated conservatively for 3 to 4 years. Nine patients with upper trunk conducting neuromas underwent neurolysis at the age of 4 to 6 months. Nerve transfer and grafting were performed in 10 patients at the age of 3 to 6 months. Upper trunk conducting neuromas were found in six of them. The follow-up period was, on average, 44.3 and 51.5 months in the nerve transfer and grafting group and in the neurolysis group, respectively. Excellent and good results in shoulder abduction, external rotation, and elbow flexion were found in 70 percent of patients in the nerve transfer and grafting group. However, none of the conservative treatment and neurolysis groups had a good result. The authors conclude that when there is no recovery of biceps contraction by 3 months of age, surgical intervention is indicated. Neuroma should be managed by nerve transfer and grafting, even though intraoperative electrophysiologic studies show that the neuroma is a conducting one.

Femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles was performed to determine its protective effect on the hand intrinsic muscles. Seven cases of brachial plexus root avulsion treated from May of 1989 to October of 1991 were involved. The femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles was done at the same stage of multiple neurotization. The muscular branches derived from the femoral nerve were isolated and coapted with the thenar muscle branch of the median nerve and the deep branch of the ulnar nerve. A groin flap was harvested simultaneously to form a skin-tube pedicle that covered the nerve bridge. At the second stage, when regeneration of the median and ulnar nerves was found to reach as far as the level of the wrist, the femoral nerve was divided and the muscular branches of the thenar and hypothenar muscles were anastomosed with the regenerated median and ulnar nerves. All the cases were followed up for more than 6 years. Six months after femoral nerve transfer, muscle power of the interosseous muscles and adductor pollicis recovered to MRC3, whereas that of the abductor pollicis brevis recovered to MRC1 to 2. Five cases underwent second-stage transfer. Four to five years of follow-up revealed that the muscle power of the interosseous muscles and adductor pollicis was MRC2 in one case, MRC1 in three cases, and MRC0 in one case. As for the donor area, muscle power of the quadriceps femoris reduced to M3 to 4 within 1 month after femoral nerve transfer and recovered to normal at 3 months. In conclusion, femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles has some protective effect on the hand intrinsic muscles. The outcome of the second stage, however, is not satisfactory.

Purpose This randomized, non-inferiority study aimed to observe the feasibility of opioid-sparing analgesia based on modified intercostal nerve block (MINB) following thoracoscopic surgery. Patients and Methods 60 patients scheduled for single-port thoracoscopic lobectomy were randomized to the intervention group or control group. After MINB was performed in both groups at the end of the surgery, the intervention group received patient controlled-intravenous analgesia (PCIA) of dexmedetomidine 0.05 µg/kg/h for 72 h after surgery, and the control group received conventional PCIA of sufentanil 3 µg/kg for 72 h. The primary outcome was a visual analog scale (VAS) on coughing 24 h after surgery. Secondary outcomes included the time to first analgesic request, pressing times of PCIA, time to first flatus, and hospital stay. Results There was no difference in the cough-VAS at 24 h (median [interquartile range]) between the intervention group [3 (2–4)] and control group [3 (2–4), P = 0.36]. The median difference (95% CI) in the cough-VAS at 24 h was [0 (0 to 1), P = 0.36]. There was no significant difference in the time to first analgesic request, pressing times of PCIA, and hospital stay between groups ( P > 0.05). A significant decrease in time to first flatus was observed in the intervention group ( P < 0.01). Conclusion Opioid-sparing analgesia provided safe and analogous postoperative analgesia with a shortened time to first flatus, compared with sufentanil-based analgesia in thoracoscopic surgery. This might be a novel method recommended for thoracoscopic surgery.

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