Nerve Root Grafting and Distal Nerve Transfers for C5-C6 Brachial Plexus Injuries

Bertelli, Jayme Augusto; Ghizoni, Marcos Flávio

doi:10.1016/j.jhsa.2010.01.004

Cited by 89 publications

(61 citation statements)

References 15 publications

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“…There is no downgrading of hand function when this strategy is employed. 5 More important, however, is to reconstruct wrist extension, as demonstrated herein, to eliminate what we propose calling the "Oberlin effect" (i.e., elbow flexion coupled with awkward wrist flexion following an Oberlin nerve transfer 16 ). Pre-and postoperative evaluations were conducted by the surgeon who operated on the patients.…”

Section: Discussionmentioning

confidence: 87%

“…Elbow flexion was reconstructed by transferring motor fascicles of the ulnar nerve preferentially related to finger flexion and intrinsic hand muscle function to the biceps motor branch, as reported previously. 5 If elbow extension was reconstructed by transferring 1 motor branch of the FCU to a triceps branch (n = 5), elbow flexion was reconstructed by transferring motor fascicles of the median nerve, rather than the ulnar nerve, to the biceps motor branch.…”

Section: Operative Proceduresmentioning

confidence: 99%

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Results of wrist extension reconstruction in C5–8 brachial plexus palsy by transferring the pronator quadratus motor branch to the extensor carpi radialis brevis muscle

Bertelli

Ghizoni

Tacca

2016

JNS

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T radiTionally, it has been accepted that if the C5-7 roots are injured, there will be palsy of shoulder abduction/external rotation, elbow flexion/extension, and thumb and finger extension.1 Although this belief is widely held, it is inconsistent with well-accepted myotome charts for the upper limb.9 For instance, it is accepted that thumb and finger extensors are innervated by the C-7 and C-8 roots; consequently, preservation of thumb and finger span should be observed in C5-7 root injuries. Bertelli and Ghizoni 4 have demonstrated that C5-7 root injuries do not cause palsies of elbow, wrist, or finger extension. In such cases, radial wrist extensors are paralyzed, but strong wrist extension is preserved because the extensor carpi ulnaris remains functional. Bertelli and Ghizoni 3 have also demonstrated that what was clinically conceived to be a C5-7 root palsy may in fact be a C5-8 root injury. Fattah et al. reached the same conclusions in children.12 In a few patients with C5-8 root palsies, thumb and finger extension is preserved because the T-1 root participates in the innervation of thumb and finger extensors.3 In these patients, if thumb and finger extensors are strong enough, wrist extension can be accomplished using these muscles. However, concomitant with the patient flexing his or her fingers to grasp an object, the wrist drops because there is no active wrist extensor to maintain the wrist in extension. When the wrist is flexed, grasp power is essentially lost.15 In C5-8 root injuries, such patients, as well as those patients with clear palsies of wrist extension, need reconstruction of wrist extensors.Very few options are available for wrist extensor reconstruction in such extended upper-type palsies of the upper limb, because only a limited number of donor nerves and tendons are available. Common donors for tendon transfers to correct a dropped wrist include the pronator teres obJective The objective of this study was to report the results of pronator quadratus (PQ) motor branch transfers to the extensor carpi radialis brevis (ECRB) motor branch to reconstruct wrist extension in C5-8 root lesions of the brachial plexus. methods Twenty-eight patients, averaging 24 years of age, with C5-8 root injuries underwent operations an average of 7 months after their accident. In 19 patients, wrist extension was impossible at baseline, whereas in 9 patients wrist extension was managed by activating thumb and wrist extensors. When these 9 patients grasped an object, their wrist dropped and grasp strength was lost. Wrist extension was reconstructed by transferring the PQ motor to the ECRB motor branch. After surgery, patients were followed for at least 12 months, with final follow-up an average of 22 months after surgery. results Successful reinnervation of the ECRB was demonstrated in 27 of the 28 patients. In 25 of the patients, wrist extension scored M4, and in 2 it scored M3. coNclusioNs In C5-8 root injuries, wrist extension can be predictably reconstructed by transferring the PQ motor branch to reinnervat...

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Section: Discussionmentioning

confidence: 87%

Section: Operative Proceduresmentioning

confidence: 99%

Results of wrist extension reconstruction in C5–8 brachial plexus palsy by transferring the pronator quadratus motor branch to the extensor carpi radialis brevis muscle

Bertelli

Ghizoni

Tacca

2016

JNS

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“…We explored the brachial plexus either using a classic L-shaped incision (n = 29) or via another oblique incision that was made slightly lateral to Chassaignac's tubercle (n = 81), as per previous reports. 6 In 95 patients, a viable upper root was identified by microscopic inspection, and this was grafted to restore elbow flexion either to the anterior division of the upper trunk, or to the musculocutaneous nerve. In 6 patients, we judged the root to be moderately compromised and combined root grafting and phrenic nerve transfer to the musculocutaneous nerve using sural grafts.…”

Section: Methods Patientsmentioning

confidence: 99%

Results of spinal accessory to suprascapular nerve transfer in 110 patients with complete palsy of the brachial plexus

Bertelli

Ghizoni

2016

SPI

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OBJECTIVE Transfer of the spinal accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with total brachial plexus palsy. However, the results of this procedure remain largely unknown. METHODS Over an 11-year period (2002–2012), 257 patients with total brachial plexus palsy were operated upon in the authors' department by a single surgeon and had the spinal accessory nerve transferred to the suprascapular nerve. Among these, 110 had adequate follow-up and were included in this study. Their average age was 26 years (SD 8.4 years), and the mean interval between their injury and surgery was 5.2 months (SD 2.4 months). Prior to 2005, the suprascapular and spinal accessory nerves were dissected through a classic supraclavicular L-shape incision (n = 29). Afterward (n = 81), the spinal accessory and suprascapular nerves were dissected via an oblique incision, extending from the point at which the plexus crossed the clavicle to the anterior border of the trapezius muscle. In 17 of these patients, because of clavicle fractures or dislocation, scapular fractures or retroclavicular scarring, the incision was extended by detaching the trapezius from the clavicle to expose the suprascapular nerve at the suprascapular fossa. In all patients, the brachial plexus was explored and elbow flexion reconstructed by root grafting (n = 95), root grafting and phrenic nerve transfer (n = 6), phrenic nerve transfer (n = 1), or third, fourth, and fifth intercostal nerve transfer. Postoperatively, patients were followed for an average of 40 months (SD 13.7 months). RESULTS Failed recovery, meaning less than 30° abduction, was observed in 10 (9%) of the 110 patients. The failure rate was 25% between 2002 and 2004, but dropped to 5% after the staged/extended approach was introduced. The mean overall range of abduction recovery was 58.5° (SD 26°). Comparing before and after distal suprascapular nerve exploration (2005–2012), the range of abduction recovery was 45° (SD 25.1°) versus 62° (SD 25.3°), respectively (p = 0.002). In patients who recovered at least 30° of abduction, recovery of elbow flexion to at least an M3 level of strength increased the range of abduction by an average of 13° (p = 0.01). Before the extended approach, 2 (7%) of 29 patients recovered active external rotation of 20° and 120°. With the staged/extended approach, 32 (40%) of 81 recovered some degree of active external rotation. In these patients, the average range of motion measured from the thorax was 87° (SD 40.6°). CONCLUSIONS In total palsies of the brachial plexus, using the spinal accessory nerve for transfer to the suprascapular nerve is reliable and provides some recovery of abduction for a large majority of patients. In a few patients, a more extensive approach to access the suprascapular nerve, including, if necessary, dissection in the suprascapular fossa, may enhance outcomes.

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“…De hecho, Bertelli y Ghizoni, preservan siempre el fascículo para el flexor carpi ulnaris para evitar el riesgo de denervar al músculo en vistas a futuras transposiciones complementarias. Estos autores han utilizado fascículos del nervio cubital que inervan la musculatura intrínseca de la mano y flexores de los dedos sin objetivar pérdida de fuerza en la mano 3 .…”

Section: Neurotización Con El Nervio Cubitalunclassified

“…. Bertelli y Ghizoni sugieren además que la transferencia de una rama del nervio radial al nervio axilar no solo mejora la función del hombro para la abducción, sino que también incrementa el grado de recuperación de la rotación externa del brazo 3 . Las ramas motoras del nervio radial, ya sea la rama motora para el vientre largo del tríceps o la rama motora para el vientre lateral del tríceps, por su localización anatómica, pueden ser coaptadas sin necesidad de injerto nervioso con el nervio axilar.…”

Section: Técnica Quirúrgicaunclassified

Técnicas de reconstrucción nerviosa en cirugía del plexo braquial traumatizado (Parte 2): Transferencias nerviosas intraplexuales

Robla-Costales¹,

Socolovsky²,

Masi³

et al. 2011

Neurocirugía

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Nerve Root Grafting and Distal Nerve Transfers for C5-C6 Brachial Plexus Injuries

Cited by 89 publications

References 15 publications

Results of wrist extension reconstruction in C5–8 brachial plexus palsy by transferring the pronator quadratus motor branch to the extensor carpi radialis brevis muscle

Results of wrist extension reconstruction in C5–8 brachial plexus palsy by transferring the pronator quadratus motor branch to the extensor carpi radialis brevis muscle

Results of spinal accessory to suprascapular nerve transfer in 110 patients with complete palsy of the brachial plexus

Técnicas de reconstrucción nerviosa en cirugía del plexo braquial traumatizado (Parte 2): Transferencias nerviosas intraplexuales

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