Repair of brachial plexus lesions by end-to-side side-to-side grafting neurorrhaphy: Experience based on 11 cases

Abstract

Eleven brachial plexus lesions were repaired using end-to-side side-to-side grafting neurorrhaphy in root ruptures, in phrenic and spinal accessory nerve neurotizations, in contralateral C7 neurotization, and in neurotization using intact interplexus roots or cords. The main aim was to approximate donor and recipient nerves and promote regeneration through them. Another indication was to augment the recipient nerve, when it had been neurotized or grafted to donors of dubious integrity, when it was not completely denervated, when it had been neurotized to a nerve with a suboptimal number of fibers, when it had been neurotized to distant donors delaying its regeneration, and when it had been neurotized to a donor supplying many recipients. In interplexus neurotization, the main indication was to preserve the integrity of the interplexus donors, as they were not sacrificeable. The principles of end-to-side neurorrhaphy were followed. The epineurium was removed. Axonal sprouting was induced by longitudinally slitting and partially transecting the donor and recipient nerves, by increasing the contact area between both of them and the nerve grafts, and by embedding the grafts into the split predegenerated injured nerve segments. Agonistic donors were used for root ruptures and for phrenic and spinal accessory neurotization, but not for contralateral C7 or interplexus neurotization. Single-donor single-recipient neurotization was successfully followed in phrenic neurotization of the suprascapular (3 cases) and axillary (1 case) nerves, spinal accessory neurotization of the suprascapular nerve (1 case), and dorsal part of contralateral C7 neurotization of the axillary nerve (2 cases). Apart from this, recipient augmentation necessitated many donor to single-recipient neurotizations. This was successfully performed using phrenic-interplexus root to suprascapular transfers (2 cases), phrenic-contralateral C7 to suprascapular transfer (1 case), and spinal accessory-interplexus root to musculocutaneous transfer (1 case). Both recipient augmentation and increasing the contact area between grafts and recipients necessitated single or multiple donor to many recipient neurotizations. This was applied in root ruptures (3 cases), with results comparable to those obtained in classical nerve-grafting techniques. It was also applied in ventral C7 transfer to the lateral or medial cords (3 cases) with functional recovery occurring in the biceps and pronator teres muscles, but not in dorsal C7 transfer to the axillary and radial nerves (3 cases) with functional recovery occurring in the deltoid and triceps muscles, and in whole C7 transfer to C5, 6, 7, 8T1 roots with functional recovery occurring in the deltoid (M4), biceps (M4), pronator teres (M4), and triceps (M3) (3 cases), and less so in the flexor carpi ulnaris and FDP (M3) (1 case) and the extensor digitorum longus (M3) (1 case). Contralateral C7 transfer to the lateral and posterior cords (4 cases) was followed by cocontractions that took 1 year to improve and that involved the...

Bridging defects in chronic spinal cord injury using peripheral nerve grafts combined with a chitosan-laminin scaffold and enhancing regeneration through them by co-transplantation with bone-marrow-derived mesenchymal stem cells: Case series of 14 patients

“…23 Capacious reconstruction of the dura was performed to allow for cerebrospinal fluid circulation. 24 This done, sural nerves were side grafted to the cord, 25 especially on its ventral aspect 26 ; both sural nerves served as grafts; a length extending from the lateral malleolus up to middle of the popliteal fossa was obtained ( Fig. 1E and 1G-1I).…”

“…To allow for increased side neurotization, they have been extended for at least 4 cm along the ventral aspect of both superior and inferior cord segments. 25,26 Grafting in spinal cord injury differs from grafting of peripheral nerves; conduction of information is the primary aim of peripheral nerve grafting, whereas both conduction and integration of information have to be considered in spinal cord grafting. Thus, peripheral nerve grafting is primarily governed by the theory of axial axonal sprouting through the grafts 45 ; end-to-end grafting is therefore the usual procedure in peripheral nerve grafting.…”

Neurotization of the phrenic nerve with accessory nerve for high cervical spinal cord injury with respiratory distress: an anatomic study

“…Similarly, Li et al studied recovery of respiratory function by OEC transplantation and thought many possible factors may contribute to breathing improvement. They were unsure of positive contribution of OEC (1). On the contrary, nerve transfer procedures are routinely performed for severe brachial plexus injury (BPI).…”

“…On the contrary, nerve transfer procedures are routinely performed for severe brachial plexus injury (BPI). Microsurgeons have achieved satisfactory improvement in muscle power, movement of joint and preventing deformity (1,3,7,14,21,23), which provides a basis for utilizing autologous nerve transfer in recovery of respiratory function following high cervical injury (9). Gauthier et al studied unilateral recurrent laryngeal nerve-phrenic nerve anastomosis for improving respiratory function of rats after high cervical spinal cord injury.…”

Collateral sprouting axons of end-to-side nerve coaptation in the avulsion of ventral branches of the C5-C6 spinal nerves in the brachial plexus

“…We focused on the dermatomes innervated by nerves derived from C5, C6, and C7. This test was performed at 1 day after surgery and at 4,8,12,16, and 20 weeks after surgery. For this study, we used the following 4-point grading scale: 0 -no response; 1 -mild response, the animal presents a very weak reaction; 2 -moderate response, the animal shows a reaction in response to stimuli; and 3 -the animal exhibits a significant response to stimuli.…”