Brachial Plexus Avulsion Research Articles

Restoration of active pick-up function in patients with total brachial plexus avulsion injuries.

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Structural and Functional Substitution of Deleted Primary Sensory Neurons by New Growth from Intrinsic Spinal Cord Nerve Cells: An Alternative Concept in Reconstruction of Spinal Cord Circuits.

In a recent clinical report, return of the tendon stretch reflex was demonstrated after spinal cord surgery in a case of total traumatic brachial plexus avulsion injury. Peripheral nerve grafts had been implanted into the spinal cord to reconnect to the peripheral nerves for motor and sensory function. The dorsal root ganglia (DRG) containing the primary sensory nerve cells had been surgically removed in order for secondary or spinal cord sensory neurons to extend into the periphery and replace the deleted DRG neurons. The present experimental study uses a rat injury model first to corroborate the clinical finding of a re-established spinal reflex arch, and second, to elucidate some of the potential mechanisms underlying these findings by means of morphological, immunohistochemical, and electrophysiological assessments. Our findings indicate that, after spinal cord surgery, the central nervous system sensory system could replace the traumatically detached original peripheral sensory connections through new neurite growth from dendrites.

Delayed Spinal Cord-Brachial Plexus Reconnection after C7 Ventral Root Avulsion: The Effect of Reinnervating Motoneurons Rescued by Riluzole Treatment.

Ventral root avulsion induces dramatic loss of the affected spinal cord motoneurons. The neuroprotective effect of riluzole has been previously proven on the injured motoneurons: the vast majority of them can be rescued even when they have no possibility to regenerate their axons. In this study the number of injured motoneurons rescued by riluzole treatment and their capacity to reinnervate the denervated forelimb muscles was investigated. Surgical reconnection with a peripheral nerve graft between the affected spinal cord segment and the C7 spinal nerve was established immediately or with 1- and 3-week delay after avulsion. Avulsion and immediate reconnection of the motoneuron pool to the spinal nerve resulted in moderate reinnervation of the spinal nerve (281 ± 23 standard error of mean [SEM] retrogradely labeled motoneurons), whereas treatment of the injured motoneurons with riluzole yielded considerably higher numbers of reinnervating motoneurons (548 ± 18 SEM). Reconnection of the motor pool with the C7 spinal nerve with 1-week delay allowed fewer motor axons to reinnervate their targets in control and riluzole-treated animals (159 ± 21 vs. 395 ± 16 SEM). A clinically relevant 3-week delay in reconnection further reduced the number of reinnervating motoneurons (76 ± 22 SEM), but riluzole pre-treatment still enabled a significant number of rescued motoneurons (396 ± 17 SEM) to regenerate their axons into the C7 spinal nerve. These results show that those injured adult motoneurons that are rescued by riluzole treatment started immediately after the avulsion injury are able to reinnervate their targets even if they are provided with a conduit several weeks after the primary injury. This finding suggests that partial rescue of injured motoneurons with riluzole in patients who suffered a brachial plexus avulsion injury may provide an available pool of surviving motoneurons for late reconnection/reimplantation surgeries.

Repair of the musculocutaneous nerve using the vagus nerve as donor by helicoid end-to-side technique: an experimental study in rats.

Although several donor nerves can be chosen to repair avulsed brachial plexus nerve injury, available nerves are still limited. The purpose of this study is to validate whether the vagus nerve (VN) can be used as a donor. Eighteen Sprague-Dawley male rats were divided into three groups (n = 6). The right musculocutaneous nerve (McN) was transected with differing subsequent repair. (1) HS-VN group: a saphenous nerve (SN) graft-end was helicoidally wrapped round the VN side (epi-and perineurium was opened) with a 30 ° angle, distal SN end was coapted to the McN with end-to-end repair. (2) EE-PN group: a SN was interpositionally grafted between the transected phrenic nerve (PN) and the McN by end-to-end coaptation. (3) Sham control group: McN was transected and not repaired and postoperative vital signs were checked daily. At three months, electrophysiology, tetanic force, wet biceps muscle weight, and histology were evaluated. Every tested mean value in HS-VN group was significantly greater than the EE-PN or the sham control groups (p < 0.05 or p < 0.005). The mean recovery ratio of regenerated nerve fibers was 96% and, in HS-VN group, the mean recovery ratio of CMAP was 79%. No vital signs changed in any group. There was no statistical difference (p > 0.5) between the mean VN nerve-fiber numbers of the segments proximal (2237 ± 134) and distal (2150 ± 156) to the VN graft-attachment site. Histological analysis revealed no axon injury or intraneural scarring at any point along the VN. This study demonstrated that VN is a practical and reliable donor nerve for end-to-side nerve transfer. © 2017 Wiley Periodicals, Inc.

Scapulothoracic Dissociation: Evaluation and Management.

Scapulothoracic dissociation is a rare, potentially limb- and life-threatening injury of the shoulder girdle. The injury is characterized by lateral displacement of the scapula resulting from traumatic disruption of the scapulothoracic articulation. The typical physical examination findings consist of substantial swelling of the shoulder girdle, along with weakness, numbness, and pulselessness in the ipsilateral upper extremity. Radiographic evaluation includes measurement of the scapular index on a nonrotated chest radiograph and assessment for either a distracted clavicle fracture or a disrupted acromioclavicular or sternoclavicular joint. Although vascular injury occurs in most patients, emergent surgery is performed only in patients with either limb-threatening ischemia or active arterial hemorrhage. Management of neurologic injury can be delayed if necessary. The location and severity of neurologic injury determine whether observation, nerve grafting, nerve transfer, or above-elbow amputation is performed. Skeletal stabilization procedures include plate fixation of clavicle fractures and reduction of distracted acromioclavicular or sternoclavicular joints. The extent of neurologic injury determines clinical outcomes. Medical Outcomes Study 36-Item Short Form scores are significantly lower in patients with complete brachial plexus avulsion injury than in patients with postganglionic injury.

Long-Term Outcome of Brachial Plexus Reimplantation After Complete Brachial Plexus Avulsion Injury.

BackgroundComplete brachial plexus avulsion injury is a severe disabling injury due to traction to the brachial plexus. Brachial plexus reimplantation is an emerging surgical technique for the management of complete brachial plexus avulsion injury.ObjectiveWe assessed the functional recovery in 15 patients who underwent brachial plexus reimplantation surgery after complete brachial plexus avulsion injury with clinical examination and electrophysiological testing.MethodsWe included all patients who underwent brachial plexus reimplantation in our institution between 1997 and 2010. Patients were assessed with detailed motor and sensory clinical examination and motor and sensory electrophysiological tests.ResultsWe found that patients who had reimplantation surgery demonstrated an improvement in Medical Research Council power in the deltoid, pectoralis, and infraspinatous muscles and global Medical Research Council score. Eight patients achieved at least grade 3 MRC power in at least one muscle group of the arm. Improved reinnervation by electromyelography criteria was found in infraspinatous, biceps, and triceps muscles. There was evidence of ongoing innervation in 3 patients. Sensory testing in affected dermatomes also showed better recovery at C5, C6, and T1 dermatomes. The best recovery was seen in the C5 dermatome.ConclusionsOur results demonstrate a definite but limited improvement in motor and sensory recovery after reimplantation surgery in patients with complete brachial plexus injury. We hypothesize that further improvement may be achieved by using regenerative cell technologies at the time of repair.

Dynamic alterations of the levels of tumor necrosis factor-α, interleukin-6, and interleukin-1β in rat primary motor cortex during transhemispheric functional reorganization after contralateral seventh cervical spinal nerve root transfer following brachial plexus avulsion injuries.

The transfer of a contralateral healthy seventh cervical spinal nerve root (cC7) to the recipient nerve in the injured side is considered a reliable and effective procedure for restoration of the physiological functions of an injured hand after brachial plexus root avulsion injury (BPAI). Growing evidence shows that the transhemispheric cortical reorganization is induced after cC7 nerve transfer surgery. However, little is known about the underlying molecular mechanism. Proinflammatory cytokines reportedly play an important role in the neural plasticity. We hypothesize that proinflammatory cytokines are involved in the transhemispheric functional reorganization after cC7 transfer. In the present study, we investigated the level of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-1β (IL-1β) in the rat primary motor cortex after cC7 transfer following BPAI by enzyme-linked immunosorbent assay. The results showed that, in the sham group, no statistical significance was observed between the level of TNF-α, IL-6, and IL-1β at each time point after the operation compared with that at day 0, respectively. However, in the unrepaired and repaired groups, the level of TNF-α, IL-6, and IL-1β changed dynamically. The study is the first to provide evidence for the involvement of proinflammatory cytokines in transhemispheric functional reorganization after cC7 transfer following BPAI, which are useful for understanding the underlying mechanism.

Free Functioning Gracilis Muscle Transfer With and Without Simultaneous Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion After Traumatic Adult Brachial Pan-Plexus Injury

After complete 5-level root avulsion brachial plexus injury, the free-functioning muscle transfer (FFMT) and the intercostal nerve (ICN) to musculocutaneous nerve (MCN) transfer are 2 potential reconstructive options for restoration of elbow flexion. The aim of this study was to determine if the combination of the gracilis FFMT and the ICN to MCN transfer provides stronger elbow flexion compared with the gracilis FFMT alone. Sixty-five patients who underwent the gracilis FFMT only (32 patients) or the gracilis FFMT in addition to the ICN to MCN transfer (33 patients) for elbow flexion after a pan-plexus injury were included. The 2 groups were compared with respect to postoperative elbow flexion strength according to the modified British Medical Research Council grading system as well as preoperative and postoperative Disability of the Arm, Shoulder, and Hand scores. Two subgroup analyses were performed for the British Medical Research Council elbow flexion strength grade: FFMT neurotization (spinal accessory nerve vs ICN) and the attachment of the distal gracilis tendon (biceps tendon vs flexor digitorum profundus/flexor pollicis longus tendon). The proportion of patients reaching the M3/M4 elbow flexion muscle grade were similar in both groups (FFMT vs FFMT+ ICN to MCN transfer). Statistically significant improvement in postoperative Disability of the Arm, Shoulder, and Hand score was found in the FFMT+ ICN to MCN transfer group but not in the FFMT group. There was a significant difference between gracilis to biceps (M3/M4= 52.6%) and gracilis to FDP/flexor pollicis longus (M3/M4= 85.2%) tendon attachment. The use of the ICN to MCN transfer associated with the FFMT does not improve the elbow flexion modified British Medical Research Council grade, although better postoperative Disability of the Arm, Shoulder, and Hand scores were found in this group. The more distal attachment of the gracilis FFMT tendon may play an important role in elbow flexion strength. Therapeutic IV.

Functional connectivity of motor cortical network in patients with brachial plexus avulsion injury after contralateral cervical nerve transfer: a resting-state fMRI study

IntroductionThe purpose of this study is to assess the functional connectivity of the motor cortical network in patients with brachial plexus avulsion injury (BPAI) after contralateral C7 nerve transfer, using resting-state functional magnetic resonance imaging (RS-fMRI).MethodsTwelve patients with total brachial plexus root avulsion underwent RS-fMRI after contralateral C7 nerve transfer. Seventeen healthy volunteers were also included in this fMRI study as controls. The hand motor seed regions were defined as region of interests in the bilateral hemispheres. The seed-based functional connectivity was calculated in all the subjects. Differences in functional connectivity of the motor cortical network between patients and healthy controls were compared.ResultsThe inter-hemispheric functional connectivity of the M1 areas was increased in patients with BPAI compared with the controls. The inter-hemispheric functional connectivity between the supplementary motor areas was reduced bilaterally.ConclusionsThe resting-state inter-hemispheric functional connectivity of the bilateral M1 areas is altered in patients after contralateral C7 nerve transfer, suggesting a functional reorganization of cerebral cortex.

Two cases of brachial plexus avulsion injury with consideration for postoperative opioid dosage reduction

Two cases of brachial plexus avulsion injury with consideration for postoperative opioid dosage reduction

A new model for the study of neuropathic pain after brachial plexus injury

The study was to introduce a new and reliable behavioral model of upper trunk of brachial plexus avulsion for the study of persistent neuropathic pain. 60 rats were divided into three groups randomly: upper trunk of brachial plexus avulsion (UTBPA) group (20), global brachial plexus avulsion (GBPA) group (20), and sham- operated group (20). The animals were tested for behavioral responsiveness before surgeries and 3, 7, 14, 21, 28, 56, 84days after surgeries. The injured level of spinal cord was resected and the sections were processed for GFAP (astrocyte) and Iba1 (microglia) immunohistochemistry 3 weeks after surgeries. The UTBPA group developed significant signs both of mechanical and cold hypersensitivity, which matched the immunohistochemistry result, as well as the nature of avulsion was close to the clinical type of injury, the UTBPA group could be used as a suitable and effective persistent neuropathic pain model following brachial plexus injury.

Outcome Comparison of Nerve Transfer with Different Donor Nerves in a Rat Model.

The phrenic nerve and the contralateral seventh cervical (C7) nerve root are the most commonly used donor nerves in the treatment of total brachial plexus avulsion. The aim of this study was to determine if the phrenic nerve or the contralateral C7 nerve root yields a superior outcome for nerve transfer. A total of 60 Sprague-Dawley rats were randomly assigned to 1 of 3 groups. In Group A the phrenic nerve was used as the donor nerve; in Group B the contralateral C7 nerve root nerve was used as the donor nerve; in Group C the nerve was directly sutured. The results of behavioral assessment, electrophysiology, histology, nerve fiber count and muscle weight at 24 weeks postoperatively were recorded. Group A showed a faster recovery time compared to Group B; however Group B showed a better functional recovery at the final outcome assessment compared to Group A. The contralateral C7 nerve root was better as the donor nerve for nerve transfer in the treatment of total brachial plexus avulsion.

Functional Outcome of Nerve Transfers for Traumatic Global Brachial Plexus Avulsion

Objective: We sought to combine Medical Research Council (MRC) grading with the Disability of the Arm, Shoulder and Hand (DASH) questionnaires and Numerical Rating Scale (NRS) for pain to evaluate the functional outcome of patients who suffered complete brachial plexus avulsion before and after nerve transfers. Methods: The author carried out a retrospective review of 37 patients with global avulsion of the brachial plexus from 2010 to 2012. All of them underwent nerve transfers in Hua Shan Hospital in Shanghai. They were followed up for over 3 years for physical examination and responding to the questionnaires of DASH, NRS, as well as the satisfaction with the surgery. Results: The mean time to surgery was less than 6 months and the mean follow-up period was 4.59 years. The effective motor recovery rate was 54%, 86%, 46%, and 43%, respectively, in supraspinatus, biceps, triceps, and finger flexor. Patients who underwent nerve transfers scored consistently better on the DASH score and NRS score than those before surgery. There was also a significant correlation between the change in NRS scores and patient satisfaction. Conclusion: This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients’ self-assessments. Neurolysis after neurotizations correlated positively with functional outcomes.

Contralateral C7 Transfer via Both Vascularized Ulnar Nerve and Medial Antebrachial Cutaneous Nerve With the Ulnar Artery Anastomosed to the Arteria transversa Colli to Repair Brachial Plexus Avulsion

Background: Contralateral C7 nerve transfer to the median nerve has been used in an attempt to restore finger flexion in patients with total brachial plexus avulsion injury. However, the results have not been satisfactory mainly because of the requirement to use a long bridging nerve graft, which causes an extended nerve regeneration process and irreversible muscle atrophy. A new procedure involving contralateral C7 nerve transfer via both vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery anastomosed to the arteria transversa colli is presented here. Methods: It was performed in 25 patients with total brachial plexus avulsion injury. Contralateral C7 nerve root was coapted to the distal end of the ipsilateral vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery is anastomosed to the arteria transversa colli. The ulnar nerve was secured to the median nerve, and medial antebrachial cutaneous nerve was used to repair musculocutaneous nerve. Electromyography and ultrasonography were used to evaluate the early recovery. Recovery of finger, wrist, and elbow flexion was evaluated with the use of the modified British Medical Research Council muscle grading system. Results: Electromyography showed the early recovery by 3 months postoperatively, and smooth blood flow at the anastomotic stoma can be seen through ultrasound. The mean follow-up period (and standard deviation) was 20 ± 6 months. Motor function with a grade of M3+ or greater was attained in 60% of the patients for elbow flexion, 64% of the patients for finger flexion, 53% of the patients for thumb flexion, and 72% of the patients for wrist flexion. Conclusions: Contralateral C7 nerve transfer via both vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery anastomosed to the arteria transversa colli speeds up the nerve regeneration in patients with total brachial plexus avulsion injury and improve the utilization of contralateral C7 fiber. There was satisfactory recovery of finger flexion and wrist flexion in this series.

Long-term Observation of Respiratory Function After Unilateral Phrenic Nerve and Multiple Intercostal Nerve Transfer for Avulsed Brachial Plexus Injury

Objective: Either phrenic nerve transfer (PNT) or multiple intercostal nerve transfer (MIT) alone was reported having no significant impact on pulmonary function in short or medium term. But it has rarely been reported whether the combination of PNT-MIT could influence respiratory function in the long term. In this study, pulmonary and diaphragmatic functions were compared between PNT and PNT-MIT after 7 to 19 years (mean 10 years) postoperatively. Methods: Twenty-three adult patients with brachial plexus avulsion injuries (BPAI) who underwent PNT-MIT were compared with 19 corresponding adult patients who underwent PNT only. Pulmonary function testing, phrenic nerve conduction study, and chest fluoroscopy were performed to assess ventilation, diaphragmatic response, and excursion. In the PNT-MIT group, further comparison was performed to investigate whether the number of transferred intercostal nerves and the timing of MIT would influence the results. Results: In PNT-MIT group, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and total lung capacity (TLC) were 73.69%, 72.04%, and 74.81%, respectively, of predicted values without significant differences from the PNT group. Diaphragmatic paralysis permanently existed with hemidiaphragm elevation of 1 to 1.5 intercostal spaces (ICSs) and near one ICS reduced excursion. No statistically significant difference was found between PNT and PNT-MIT groups. Furthermore, in the PNT-MIT group, the transfer of 3 and 4 intercostal nerves resulted in no further decrease in pulmonary function than that of 2 intercostal nerves. No significant difference was found when PNT-MIT was performed at the same stage or at an interval of 1 or 2 months. Conclusions: In the long-term observation, PNT-MIT did not result in additional impairment in respiratory function in adult patients compared with PNT alone. Transfer of 2 to 4 intercostal nerves at 1- to 2-month delay after PNT is a safe method for treating BPAI.

Long-term Ongoing Cortical Remodeling After Contralateral C-7 Nerve Transfer

Object: Contralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure, the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer. Methods: In this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional magnetic resonance imaging studies were used for the investigation of long-term cerebral plasticity. Results: The neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period, at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation. Conclusions: The authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.

The Surgical Strategy for the Treatment of Total Brachial Plexus Avulsion Injury Patient

Objective: The total brachial plexus avulsion injury (BPAI) patients were treated in many organizations in the world, but the results reported differ significantly regarding different surgical strategy. Thus, this study aimed to evaluate the outcomes of different methods of nerve transfer and to determine a relatively optimal surgical strategy for treatment of total BPAI patients. Methods: A retrospective review was conducted on 73 patients with total BPAI who were treated with nerve transfer. The elbow flexion was reconstructed in 73 patients with phrenic nerve (PN) or intercostal nerves (ICNs) or contralateral C7 (cC7) transfer. The shoulder abduction was reconstructed in 73 patients with spinal accessory nerve (SAN) or ICNs transfer or both. Elbow extension was reconstructed in 35 patients with ICNs or cC7 transfer. Wrist and finger flexion were reconstructed in 73 patients with cC7 transfer. Wrist and finger extension were reconstructed in 31 patients with ICNs transfer. The mean follow-up period was 7.3 years. Results: The effective recovery rate were 79.5% in elbow flexion, 76.7% in shoulder abduction, 45.7% in elbow extension, 54.8% in wrist and finger flexion, 57.5% in median nerve area sensation, and 38.7% in wrist and finger extension. No significant difference was found in elbow flexion recovery between the patients with PN, ICN, or cC7 transfer. Shoulder abduction was significantly better in patients with SAN combined with ICNs transfer while no significant difference was found between the patients with anterior or posterior approach SAN transfer. Elbow extension was significantly better in patients with ICNs transfer. Entire cC7 transfer achieved significantly better recovery in wrist and finger flexion than partial cC7 transfer. Conclusion: For the treatment of total BPAI patients, we recommend PN transfer for elbow flexion, SAN combined with ICNs transfer for shoulder abduction, ICNs transfer for elbow extension, entire cC7 transfer for wrist and finger flexion, and ICNs transfer for finger extension, whereas for the elder or PN-injured patients, we recommend SAN combined with ICNs transfer for shoulder abduction, entire cC7 transfer for elbow flexion and wrist and finger flexion, and ICNs transfer for elbow extension and wrist and finger extension.

Elbow Flexion Reconstruction by End-to-Side Neurorrhaphy in Phrenic Nerve Transfer

Purpose: Phrenic nerve transfer (PNT) has proven to be an effective approach for the treatment of brachial plexus avulsion injuries (BPAI). But there have been major concerns about the possibility of deterioration of the pulmonary and diaphragm functions after PNT. In the current study, we performed end-to-side neurorrhaphy in PNT for BPAI patients while minimizing the potential damage to the diaphragm function. We prospectively assessed the efficacy of end-to-side neurorrhaphy for PNT in reconstructing the elbow flexion by regenerating the anterior division of the upper trunk (ADUT) or the musculocutaneous nerve (McN) in a series of 5 patients. Methods: From January to June 2008, 5 patients with BPAI underwent PNT with an end-to-side fashion, to regenerate the ADUT (3 patients) or the McN (2 patients). The operative delay after injury was from 1 to 6 months (mean, 2.5 months). The follow-up duration was 24 months. The regeneration outcomes of ADUT or McN were evaluated with an electromyography (EMG) test. The recovery of elbow flexion power was recorded according to the British Medical Research Council (MRC) grading system. Pulmonary function tests (PFTs) were used to assess the respiratory function. Chest fluoroscopy and phrenic nerve conduction studies were performed in the evaluation of phrenic nerve and diaphragm functions. Results: At the final visits after 2 years, all patients regained various degrees of biceps strength (M4 in 2 patients, M3 in 1 patient, M2 in 1 patient, and M1 in 1 patient). At 24 months after surgery, the average prolongation of latency of PN was 2.88 seconds, and the average decrease in amplitude from before the operation was 32.4%. The diaphragm function and PFTs were normal in all patients. Conclusions: PNT with end-to-side neurorrhaphy could provide functional biceps recovery in a majority of patients, with preservation of donor nerve function.

Contralateral C7 Transfer via the Prespinal and Retropharyngeal Route to Repair C6 and C8 for Patients With Total Brachial Plexus Root Avulsion

Objective: We sought to investigate a new way of neurotization to reconstruct the flexion of elbow, wrist, and finger of patients with total brachial plexus root avulsion. Methods: Nine patients were treated from October 2008 to November 2009. Their ages ranged from 6 to 45 years (average, 25 years). The operative delay was from 4 to 16 weeks (mean, 9 weeks). All patients had total brachial plexus avulsion, confirmed by intraoperative finding and electromyography. After a prespinal and retropharyngeal tunnel was made, the contralateral C7 nerve root was transferred to repair both C6 and C8 of the injured side via this route, with nerve grafting. The nerve graft was 5.61 ± 1.91 cm long for repairing C6 and 5.78 ± 2.32 cm long for repairing C8. Results: In 2 cases, we found early functional recovery of elbow flexion at the seventh month postoperatively. In all cases, we found recovery of elbow flexion at the 12th month postoperatively, and recovery of wrist and finger flexion at the 15th month postoperatively. Conclusion: This way of neurotization shortens the distance of nerve regeneration, and the nerve fibers of contralateral C7 are fully used to reconstruct the flexion of elbow, wrist, and finger. Results of follow-up show this method favors nerve regeneration and functional recovery.

Transferência de nervos (neurotizações) no tratamento das lesões traumáticas do plexo braquial

Brachial plexus avulsion injuries are usually caused by car and motorcycle accidents. Their consequences are devastating and represent a challenge to the surgeons who assist these patients. Positive results of this procedure depend on the interval between the injury and the definitive treatment. The treatment of brachial plexus avulsion injuries invariably involves the use of neurolysis, direct nerve repair, nerve grafts, and neurotization procedures. Several nerves have been used as donors in neurotizations. In general, there are two types of donor: extraplexal (intercostal, spinal accessory, and phrenic nerves, motor branches of the cervical plexus, and contralateral C7 root) and intraplexal (proximal spinal nerve stumps or collateral motor branches of the preserved brachial plexus). In fact, the intraplexal neurotization represents the classical form of nerve transfers.