Comparison of Surgical Strategies between Proximal Nerve Graft and/or Nerve Transfer and Distal Nerve Transfer Based on Functional Restoration of Elbow Flexion: A Retrospective Review of 147 Patients

Abstract

Background: Surgical strategy to treat incomplete brachial plexus injury with palsies of the shoulder and elbow by using proximal nerve graft/transfer or distal nerve transfer is still debated. The aim of this study was to compare both strategies with respect to the recovery of elbow flexion. Methods: One hundred forty-seven patients were enrolled: 76 patients underwent reconstruction using proximal nerve graft/transfer, and 71 patients underwent reconstruction using distal nerve transfer. All patients were evaluated preoperatively and postoperatively to assess the recovery rate and muscle strength of elbow flexion. Shoulder abduction and hand grip power were also recorded to assess any concomitant postoperative changes between the two methods. Results: The best recovery rate for functional elbow flexion (p = 0.006) and the fastest recovery to M3 strength (p < 0.001) were found in the double fascicular transfer group. However, recovery of shoulder abduction with proximal nerve graft/transfer was significantly better than with distal nerve transfer (80.3 percent versus 66.2 percent in shoulder abduction ≥60 degrees; and 56.6 percent versus 38.0 percent in shoulder abduction ≥90 degrees). A significant decrease in grip strength between the operative and nonoperative hands was also found in patients undergoing distal nerve transfer (p = 0.001). Conclusions: Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow function simultaneously. Distal nerve transfer can offer more efficient elbow flexion. Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Starting A Peripheral Nerve Surgery Unit in an Area of Limited Resources - Our Experience

“…The workhorse of brachial plexus repair surgery is still largely the neurotization transfers and nerve grafting [5,6,13,17,19,23,24,29,38,42,44,48,50,51]. The muscles of the shoulder and the biceps brachii have classically been the main targets for repair of brachial plexus injuries [17,29,38,48]. However, there is now more importance on equally focusing on restoring at least elbow extension for functionality and even newer attempts at selective reinnervation of the median nerve for prehensile hand function or pincer grip [33,39,42].…”

“…However, there is now more importance on equally focusing on restoring at least elbow extension for functionality and even newer attempts at selective reinnervation of the median nerve for prehensile hand function or pincer grip [33,39,42]. For proximal upper limb functions, the two most important distal transfers are neurotization of the suprascapular nerve with spinal accessory nerve through a posterior approach for shoulder abduction and Oberlin's double fascicular transfer of ulnar and median nerve fascicles to the biceps and brachialis branches of the musculocutaneous nerve for elbow flexion [8,19,23,24,26,31,33,38,47]. Case series reports have demonstrated very low long term donor nerve functional impairment resulting from thoracoscopic full-length phrenic nerve harvest and transfers and contralateral C7 transfer [8,12,13,19,27,28,33,43,44].…”

Introductory Chapter: Brachial Plexus Injuries - Past, Present, and Future

“…Progressive improvement of the surgical techniques with direct nerve repair, nerve grafting, and particularly with nerve transfers has greatly improved the results in the brachial plexus injuries [47,[70][71][72]. Direct repair, when at all possible, is still the first choice, provided that there is no tension in the suture line [73].…”

“…Meanwhile, the nerve transfers have expanded our treatment capabilities with excellent results [72,76]. They are particularly useful in nerve injuries affecting the distal parts of the upper limb, as other techniques like the nerve repair, direct or with nerve grafts, yield poor results [47,70,77]. The growing axons coming through the nerve repair take so long to reach the hand intrinsic muscles that when they do it find them atrophied and fibrotic [78][79][80][81].…”

Future Perspectives in the Management of Nerve Injuries

“…Recently, original chart reviews directly comparing graft and transfer outcomes for specific nerve lesions have become more prevalent. [8][9][10][11][12][13][14][15][16] Similar to the meta-analyses and systematic reviews, these original articles report varying results relating to donor nerve and recipient nerve selection. Overall, they too suggest that certain distal transfers are equivalent or more than equivalent to a graft, while other transfers lead to inferior outcomes.…”