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Indian Journal of Neurotrauma 2011; 08(02): 99-103
DOI: 10.1016/S0973-0508(11)80008-0
Original article
Thieme Medical and Scientific Publishers Private Ltd.

Is fascicular selection by nerve stimulation techniques a necessity in selective nerve transfers targeted at restoration of elbow flexion in upper brachial plexus injuries?

PS Bhandari
,
HS Bhatoe
Subject Editor:
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Publication Date:
05 April 2017 (online)

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Abstract

In the restoration of elbow flexion nerve transfers have proven to be superior to muscle or tendon transfers. Biceps and brachialis muscles, the prime elbow flexors, are innervated by musculocutaneous nerve, taking its origin from the lateral cord of brachial plexus. A variety of donor nerves of both intraplexal and extraplexal sources have been used in the neurotization of this nerve. We prefer transfer of two fascicles, one each from ulnar nerve and median nerve, directly to the biceps and brachialis motor branches. Contrary to the pervious reports now we do not use nerve stimulation while selecting the ulnar and median nerve fascicles. Twenty two patients with upper plexus (C5 and C6) injuries were treated with bifascicular nerve transfer in the period between Jan 2006 and Aug 2007. All of the patients were males in the age group 18 to 35 years and motor cycle accident was the main cause of injury. The denervation period (time interval between injury and nerve surgery) averaged 5 months. Twenty one patients restored full elbow flexion (140°); one could achieve 110° of antigravity flexion. In MRC grade 16 scored M4 while 6 scored M3. Patients with good results could lift 8 kilograms of weights. In our experience, bifascicular nerve transfer using ulnar and median nerves as donor nerves is the most reliable method of restoring elbow flexion in upper brachial plexus injuries and there is no need of fascicular selection with a nerve stimulator prior to transfer.

Keywords

elbow flexion - fascicular nerve transfer - nerve stimulator
 

  • References

  • 1 Bhandari PS, Sadhotra LP, Bhargava P. et al Surgical outcomes following nerve transfers in upper brachial plexus injuries. Indian J Plast Surg 2009; 42: 150-160
    CrossrefPubMedGoogle Scholar
  • 2 Samardzic M, Grujicic D, Rasulic L, Bacetic D. Transfer of the medial pectoral nerve: Myth or reality?. Neurosurgery 2002; 50: 1277-1282
    PubMedGoogle Scholar
  • 3 Dai S-Y, Lin D-X, Han Z, Zhoug S-Z. Transfer of thoracodorsal nerve to musculocutaneous or axillary nerve in old traumatic injury. J Hand Surg 1990; 15A: 36-37
    PubMedGoogle Scholar
  • 4 Krakauer JD, Wood MD. Intercostal nerve transfer for brachial plexopathy. J Hand Surg 1994; 19A: 829-835
    PubMedGoogle Scholar
  • 5 Chuang D C C, Yeh M C, Wei F C. Intercostal nerve transfer of the musculocutneous nerve in avulsed brachial plexus injuries: Evaluation of 66 patients. J Hand Surg 1992; 17A: 822-828
    PubMedGoogle Scholar
  • 6 Minami M, Ishii S. Satisfactory elbow flexion in complete (preganglionic) brachial plexus injuries; produced by suture of third and fourth intercostals nerves to musculocutaneous nerve. J Hand Surg 1987; 12A: 1114-1118
    PubMedGoogle Scholar
  • 7 Nagano A, Tsuyama N, Ochiai N, Hara T, Takshashi M. Direct nerve crossing with the intercostals nerve to treat avulsion injuries of the brachial plexus. J Hand Surg 1989; 14A: 980-985
    PubMedGoogle Scholar
  • 8 Ogino T, Naito T. Intercostal nerve crossing to restore elbow flexion and sensibility of the hand for a root avulsion type of brachial plexus injury. Microsurgery 1995; 16: 57
    PubMedGoogle Scholar
  • 9 Gu YD, Wu MM, Zheng YL. et al Phrenic nerve transfer to treat root avulsion of brachial plexus. Chin Hand Surg 1989; 05: 1-3
    PubMedGoogle Scholar
  • 10 Gu YD, Wu MM, Zheng YL. et al Phrenic nerve transfer for brachial plexus motor neurotization. Microsurgery 1989; 10: 287-289
    CrossrefPubMedGoogle Scholar
  • 11 Allieu Y, Cenac AP. Neurotization via the spinal accessory nerve in complete paralysis due to multiple avulsion injuries of the brachial plexus. Clin Orthop 1988; 237: 67-74
    PubMedGoogle Scholar
  • 12 Songcharoen P, Mahaisavariya B, Chotigavanich C. Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus. J Hand Surg 1996; 21A: 87-90
    PubMedGoogle Scholar
  • 13 Chuang DCC, Epstein MD, Yeh MC, Wei FC. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury). J Hand Surg 1993; 18A: 285-291
    PubMedGoogle Scholar
  • 14 Oberlin C, Beal D, Leechavengvongs S, Salon A, Dauge MC, Saruj J J. Nerve transfers to biceps muscle using part of ulnar nerve for C5 – C6 avulsion of the brachial plexus; anatomical study and report of four cases. J Hand Surg 1994; 19A: 232-273
    PubMedGoogle Scholar
  • 15 Loy S, Bhatia A, Asfazadourian H, Oberlin C. Ulnar nerve fascicle transfer on to the biceps muscle nerve in C5–C6 or C5–C6–C7 avulsions of the brachial plexus: Eighteen cases. Ann Chir Main Memb Super 1997; 16: 275-284
    PubMedGoogle Scholar
  • 16 Mackinnon SE, Novak CV, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg 2005; 30A: 978-985
    PubMedGoogle Scholar
  • 17 Liverneaux PA, Diaz LC, Beaulieu JY, Durand S, Oberlin C. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstr Surg 2006; 117: 915-919
    CrossrefPubMedGoogle Scholar
  • 18 Goubier J, Teboul F. Technique of the double nerve transfer to recover elbow flexion in C5, C6 or C5–C7 brachial plexus palsy. Techniques In Hand And Upper Extremity Surgery 2007; 01 (01) 15-17
    PubMedGoogle Scholar
  • 19 Chuang DCC, Lee GW, Hashem F, Wei FC. Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: Evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 1995; 96: 122-128
    CrossrefPubMedGoogle Scholar
  • 20 Leechavengvong S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. Nerve transfer to deltoid muscles using the nerve to long head of triceps, part 2: A report of 7 cases. J Hand Surg 2003; 28A: 633-638
    PubMedGoogle Scholar
  • 21 Bhandari PS, Sadhotra LP, Bhargava P. et al Multiple nerve transfers for the reanimation of shoulder and elbow functions in irreparable C5, C6 and upper truncal lesions of the brachial plexus. Ind J Neurotruma 2008; 05: 95-104
    PubMedGoogle Scholar
  • 22 Kerr AT. The brachial plexus of nerves in man - the variations in its formation and its branches. Am J Anat 1918; 23: 285-395
    CrossrefPubMedGoogle Scholar
  • 23 Chow JA, Van Beek AL, Bilos ZJ. et al Anatomical basis for repair of ulnar and median nerves in the distal part of the forearm by group fascicular suture and nerve grafting. J Bone Joint Surg 1986; 68A: 273-280
    PubMedGoogle Scholar
  • 24 Jabaley ME, Wallace WH, Heckler FR. Internal topography of major nerves of the forearm and hand: A current view. J Hand Surg 1980; 5A: 1-18
    PubMedGoogle Scholar
  • 25 Sunderland S. The intraneural topography of the radial, median, and ulnar nerves. Brain 1945; 68: 243-299
    CrossrefPubMedGoogle Scholar
  • 26 Slingluff CI, Terzis JK, Edgerton MT. The quantitative microanatomy of the brachial plexus in man. Reconstructive relevance. In Terzis JK. ed Microreconstruction of nerve injuries. WB Saunders; Philadelphia: 1987: 285-324
    Google Scholar