Axon Counts Yield Multiple Options for Triceps Fascicular Nerve to Axillary Nerve Transfer

Khair, M. Michael; Schreiber, Joseph J.; Rosenblatt, Lauren; Byun, David J.; Lee, Steve K.; Wolfe, Scott W.

doi:10.1016/j.jhsa.2016.07.110

Cited by 24 publications

(26 citation statements)

References 19 publications

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“…Nerve transfers have become important in surgery for peripheral nerve and brachial plexus injury and now reconstruction in tetraplegia (Video S1, available online). Increased knowledge of intraneural anatomy, including axon counts, has turned nerve transfers into a powerful reconstructive tool (Garg et al., 2011; Khair et al., 2016; Schreiber et al., 2015). Nerve transfers for upper limb reconstruction after SCI are not in opposition to tendon transfers, but a complementary technique, as the combination of nerve and tendon transfers may offer the best solution for some of the patients (Bertelli and Ghizoni, 2013; van Zyl et al., 2019).…”

Section: Considerations and Discussionmentioning

confidence: 99%

Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia

Ledgard

Gschwind

2019

J Hand Surg Eur Vol

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Nerve transfers are increasingly utilized for upper limb reconstruction in tetraplegia. We reviewed the literature for results achieved by nerve transfers for elbow extension, wrist control and finger and thumb flexion and extension. Muscle strength grading was the only outcome measure consistently reported. The results confirm that nerve transfers can effectively reanimate muscles in selected cases, with comparable strength with those achieved with tendon transfer for elbow extension but inferior strength for finger and thumb flexion. Transfer of supinator nerve branches to the posterior interosseous nerve appears to be reliable and offers increased span and better hand opening than is observed after tendon transfers. Only one publication demonstrated how reinnervation of muscles with nerve transfers translated into improved function, activity and participation for patients. More prospective studies, using standardized outcome measures, are needed to define the precise role of nerve transfers.

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Section: Considerations and Discussionmentioning

confidence: 99%

Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia

Ledgard

Gschwind

2019

J Hand Surg Eur Vol

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“…The use of additional triceps branches for transfer to axillary nerve is likely an option for routine use to increase axons for innervation as the medial or long triceps is commonly sacrificed with no apparent deficits, and the lateral triceps is normally innervated by multiple branches . Future studies to assess outcomes and deficits using one or two triceps branches for transfer to axillary nerve are important; however, there is a paucity of studies that report outcomes of nerve transfers for shoulder function in children …”

Section: Discussionmentioning

confidence: 99%

Multimodal Management and Triple Nerve Transfer for Optimal Recovery of Shoulder Function Following Neonatal Brachial Plexus Palsy: A Case Report

Osorio

Lewis

Tse

2019

PM&R

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Neonatal brachial plexus palsy is a complex disorder that requires evaluation of the primary nerve injury and associated sequelae. There is no standardized approach to management, and many treatment options are available. We present a case of Erb palsy with a unique multidisciplinary approach to nonsurgical and surgical management. Inherent in the case is the complexity of decision-making, and we review the literature on treatment options and the rationale for the approach, which resulted in near normal functional recovery.

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“…Khair et al conducted an anatomical study on cadaver specimens to ascertain the axonal counts of nerves involved in this transfer, concluding that that nerve to long head of triceps has 2,302 axons, nerves to medial head has 2,198 and nerve to lateral head has 1,462. With regards to the recipient nerves in this transfer, the axonal count of the main axillary trunk was 7,887, the anterior division was 4,052 and the posterior division was 1,242 axons with the remainder innervating teres minor ( 8 ). This transfer is commonly done in combination with spinal accessory nerve (SAN) transfer to the SSN for reanimation of supraspinatus and infraspinatus muscles to provide shoulder abduction and external rotation, the importance of which was later confirmed in biomechanical studies by Crouch et al ( 9 ).…”

Section: Introductionmentioning

confidence: 96%

Defining the Reliability of Deltoid Reanimation by Nerve Transfer When Using Abnormal but Variably Recovered Triceps Donor Nerves

2021

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Upper brachial plexus injuries to the C5/6 roots or axillary nerve can result in severe deficits in upper limb function. Current techniques to reinnervate the deltoid muscle utilise the well-described transfer of radial nerve branches to triceps to the axillary nerve. However, in around 25% of patients, there is a failure of sufficient deltoid reinnervation. It is unclear in the literature if deltoid reanimation should be attempted with a nerve transfer from a weak but functioning triceps nerve. The authors present the largest series of triceps to axillary nerve transfers for deltoid reanimation in order to answer this clinical question. Seventy-seven consecutive patients of a single surgeon were stratified and analysed in four groups: (1) normal triceps at presentation, (2) abnormal triceps at presentation recovering to clinically normal function preoperatively, (3) abnormal triceps at presentation remaining abnormal preoperatively, and lastly (4) where pre-operative triceps function was deemed insufficient for use, requiring alternative reconstruction for deltoid reanimation. The authors considered deltoid re-animation of ≥ M4 as successful for the purpose of this study. Median Medical Research Council (MRC) values demonstrate group 1 achieves this successfully (M5), while median values for groups 2–4 result in M4 power (albeit with decreasing interquartile ranges). Median post-operative shoulder abduction active range of motion (AROM) values were represented by 170° (85–180) in group 1, 117.5° (97.5–140) in group 2, 90° (35–150) in group 3, and 60° (40–155) in group 4. For both post-operative assessments, subgroup analyses demonstrated statistically significant differences when comparing group 1 with groups 3 and 4 (p < 0.05), while all the other group to group pairwise comparisons did not reach significance. The authors postulated that triceps deficiency can act as a surrogate marker of a more extensive plexus injury and may predict poorer outcomes if the weakness persists representing the trending differences between groups 2 and 3. However, given no statistical differences were demonstrated between groups 3 and 4, the authors conclude that utilising an abnormal triceps nerve that demonstrates sufficient strength and redundancy intraoperatively is preferable to alternative transfers for deltoid reanimation. Lastly, in group 4 patients where triceps nerves are damaged and unusable for nerve transfer, alternative operations can also achieve sufficient outcomes and should be considered for restoration of shoulder abduction.

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Axon Counts Yield Multiple Options for Triceps Fascicular Nerve to Axillary Nerve Transfer

Cited by 24 publications

References 19 publications

Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia

Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia

Multimodal Management and Triple Nerve Transfer for Optimal Recovery of Shoulder Function Following Neonatal Brachial Plexus Palsy: A Case Report

Defining the Reliability of Deltoid Reanimation by Nerve Transfer When Using Abnormal but Variably Recovered Triceps Donor Nerves

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