A Short Scenario for Restoration of Reasonable Limb Function in Adults after Upper Brachial Plexus Injuries Using Neurotization and Combined Muscle Transfers

Abstract

Background: For managing of upper brachial plexus palsyin adult patients, many strategies should be discussed withthe patient. Primary plexus repair, nerve transfer, functionalmuscle transfer and other musculoskeletal approaches maybe followed according the suitability, merits and disadvantagesof each. Time factorsare very crucial for the sound managementfor these patients as time delay can result in a non-achievablechance loss with the neuromuscular end plates loss withintwo years following muscle denervation and progressivemusculoskeletal changes as well.Patients and Methods: Between March 2013 and June2015, six adult patients suffering from upper brachial plexusinjuries were referred to Zagazig University Hospital andoperated upon in two stages. In the first stage, two nervetransfers were performed in the same setting; neurotizationof suprascapular nerve (using a branch of spinal root of theaccessory nerve to the suprascapular nerve) and Oberlin nervetransfer (nerve fascicular transfer from the ulnar nerve tobiceps branch of the musculocutaneous nerve to reinnervatethe biceps muscle). After three to four months of the firststage, the patients were operated upon in the second stage forcombined muscles transfers in the same setting i.e. trapeziustransfer to the humerus and latissimus dorsi with teres majortransfer to rotator calf of the shoulder.Results: By the end of the tenth month of the first stage,half of patients have regained M4 elbow flexion and theremaining patients have been M3. These improvements havebeen primarily noticed by the end of the third month postoperatively.The range of elbow flexion has been graduallyimproved to (100 to 120 degree against resistance) (mean 112degree) with no noticeable deficit in the hand function as adonor site morbidity. The second stage was done 3 to 4 monthsfrom the first stage. Within 6 months of the second stage,shoulder abduction ranged from 80 to 120 degree (mean 98)with the mean of shoulder flexion 77 and externa rotation 47degrees.Conclusion: Multimodal association between distal nervestransfer and combined transfer of trabezius, latissimus dorsiand teres major muscles provides an effective and relativelya short management scenario for upper brachial plexus injuriesin adult patients.