Functional outcome of contralateral C7 nerve transfer combined with free functional gracilis transplantation to repair total brachial plexus avulsion: a report of thirty-nine cases

Abstract

Purpose Treatment of total brachial plexus avulsion (TBPA) is a challenge in the clinic, especially the restoration of hand function. The current main surgical order is from proximal to distal joints. The purpose of this study was to demonstrate the outcomes of “distal to proximal” surgical method. Methods Thirty-nine patients underwent contralateral C7 (CC7) nerve transfer to directly repair the lower trunk (CC7-LT) and phrenic nerve transfer to the suprascapular nerve (PN-SSN) during the first stage, followed by free functional gracilis transplantation (FFGT) for elbow flexion and finger extension. Muscle strength of upper limb, degree of shoulder abduction and elbow flexion, and Semmes–Weinstein monofilament test and static two-point discrimination of the hand were examined according to the modified British Medical Research Council (mBMRC) scoring system. Results The results showed that motor recovery reached a level of M3 + or greater in 66.7% of patients for shoulder abduction, 87.2% of patients for elbow flexion, 48.7% of patients for finger extension, and 25.6% of patients for finger flexion. The mean shoulder abduction angle was 45.5° (range 0–90°), and the average elbow flexion angle was 107.2° (range 0–142°), with 2.5 kg average flexion strength (range 0.5–5 kg). In addition, protective sensibility (≥ S2) was found to be achieved in 71.8% of patients. Conclusion In reconstruction of TBPA, CC7 transfer combined with free functional gracilis transplantation is an available treatment method. It could help patients regain shoulder joint stability and the function of elbow flexion and finger extension and, more importantly, provide finger sensation and partial finger flexion function. However, the pick-up function was unsatisfied, which needed additional surgery.

Der kontralaterale C7 Transfer

“…Yang et al beschreiben zudem auch den kontralateralen Transfer der L5-zur S1 Wurzel zur Therapie der Hemiplegie in Folge eines Schlaganfalls in 2 Fällen, bei denen sie zudem auch gleichzeitig einen kontralateralen C7-Transfer durchführten [32]. Auch ein selektiver kontralateraler motorischer Nervenfaszikeltransfer zur Motorisierung eines freien funktionellen Muskeltransfers, im Sinne eines kontralateralen motorischen Pectoralis major Ast für einen freien Gracilis Transfer, wurde vor kurzem beschrieben [33].…”

Complex upper extremity injuries: targeted muscle reinnervation, free functional muscle transfer, and vascularized composite allotransplantation

“…The choice of nerve will depend on the goals of a particular procedure and the options available in that setting, considering that the donor nerves available will differ substantially between a patient with a total brachial plexus avulsion and a patient with loss of elbow flexion following an oncologic extirpation. As described by Mackinnon and Novak in their 1999 seminal paper on nerve transfers, the ideal donor nerve should be expendable, located in close proximity to its intended target, contain the specific fiber types desired, and in the case of motor nerves, derive from a donor muscle that is synergistic with its destination [40] . There are several popular options for upper extremity FFMT, including but not limited to intercostal nerves, the spinal accessory nerve, the contralateral C7 root, or spared roots of the ipsilateral brachial plexus [37,38,41] .…”