Brachial Plexus Avulsion Injury Research Articles

Valproic acid protects neurons and promotes neuronal regeneration after brachial plexus avulsion.

Valproic acid has been shown to exert neuroprotective effects and promote neurite outgrowth in several peripheral nerve injury models. However, whether valproic acid can exert its beneficial effect on neurons after brachial plexus avulsion injury is currently unknown. In this study, brachial plexus root avulsion models, established in Wistar rats, were administered daily with valproic acid dissolved in drinking water (300 mg/kg) or normal water. On days 1, 2, 3, 7, 14 and 28 after avulsion injury, tissues of the C5-T1 spinal cord segments of the avulsion injured side were harvested to investigate the expression of Bcl-2, c-Jun and growth associated protein 43 by real-time PCR and western blot assay. Results showed that valproic acid significantly increased the expression of Bcl-2 and growth associated protein 43, and reduced the c-Jun expression after brachial plexus avulsion. Our findings indicate that valproic acid can protect neurons in the spinal cord and enhance neuronal regeneration following brachial plexus root avulsion.

Outcome of contralateral C7 nerve transferring to median nerve

Background Contralateral C7 (cC7) transfer had been widely used in many organizations in the world, but the outcomes were significantly different. So the purpose of the study was to evaluate the outcome of patients treated with cC7 transferring to median nerve and to determine the factors affecting the outcome of this procedure. Methods A retrospective review of 51 patients with total root avulsion brachial plexus injuries who underwent cC7 transfer was conducted. All of the surgeries were performed with two surgery stages and median nerve was the recipient nerve. The cC7 nerve was used in three different ways. The entire C7 root was used in 11 patients; the posterior division together with the lateral part of the anterior division was used in 15 patients; the anterior or the posterior division alone was used in 25 patients. The mean follow-up period was 6.9 years. Results The efficiency of the surgery in these 51 patients was 49.02% in motor and 62.75% in sensory function. The patients with entire C7 root transfer obtained significantly better recovery in both motor and sensory function than the patients with partial C7 transfer. The best function recovery could be induced if the interval between the two surgery stages was 4-8 months. Conclusions cC7 transfer is an effective procedure in repairing median nerve. But using the entire C7 root transfer can obtain better recovery; so we emphasize using the entire root as the donor. The optimal interval between two surgery stages is 4-8 months.

Surgical treatment for total root avulsion type brachial plexus injuries by neurotization: A prospective comparison study between total and hemicontralateral C7 nerve root transfer

Purpose: We conducted a clinical study to evaluate the effects of neurotization, especially comparing the total contralateral C7 (CC7) root transfer to hemi-CC7 transfer, on total root avulsion brachial plexus injuries (BPI). Methods: Forty patients who received neurotization for BPI were enrolled in this prospective study. Group 1 (n = 20) received hemi-CC7 transfer for hand function, while group 2 (n = 20) received total-CC7 transfer. Additional neurotization included spinal accessory, phrenic, and intercostal nerve transfer for shoulder and elbow function. The results were evaluated with an average of 6 years follow-up. Results: Group 1 had fewer donor site complications (15%) than group 2 (45%); group 2 had significantly better hand M3 and M4 motor function (65%) than group 1 (30%; P = 0.02). There was no difference in sensory recovery. Significantly, better shoulder function was obtained by simultaneous neurotization on both suprascapular and axillary nerves. Conclusions: Total-CC7 transfer had better hand recovery but more donor complications than hemi-CC7. Neurotization on both supra-scapular and axillary nerves improved shoulder recovery. © 2013 The Authors. Microsurgery published by Wiley Periodicals, Inc. Microsurgery 34:91–101, 2014.

Outcome of contralateral C7 transfer to two recipient nerves in 22 patients with the total brachial plexus avulsion injury

The treatment of total brachial plexus avulsion injury is difficult with unfavorable prognosis. This report presents our experience on the contralateral C7 (CC7) nerve root transfer to neurotize two recipient nerves in the patients with total BPAI. Twenty-two patients underwent CC7 transfer to two target nerves in the injured upper limb. The patients' ages ranged from 13 to 48 years. The entire CC7 was transferred to pedicled ulnar nerve in the first stage. The interval between trauma and surgery ranged from 1 to 13 months. The ulnar nerve was transferred to recipients (median nerve and biceps branch or median nerve and triceps branch) at 2-13 months after first operation. The motor recovery of wrist and finger flexor to M3 or greater was achieved in 68.2% of patients, the sensory recovery of median nerve area recovered to S3 or greater in 45.5% of patients. The functional recovery of elbow flexor to M3 or greater was achieved in 66.7% of patients with repair of biceps branch and 20% of patients with repair of the triceps branch (P < 0.05). There were no statistical differences in median nerve function recovery at comparisons of the age younger and older than 20-years-old and the intervals between trauma and surgery. In conclusion, the use of CC7 transfer for repair two recipient nerves might be an option for treatment of total BPAI. The functional recovery of the repaired biceps branch appeared to be better than that of the triceps branch.

The clinical research of restoring the global upper limber function in traumatic total brachial plexus avulsion injuries

Objective To observe the outcomes of the modified multiple nerve transfer s combined with the late hand function reconstruction to restore the active pick-up function of the paralyzed upper extremity in patients with total brachial plexus avulsion injuries (TBPAI).Methods 33 patients suffered with TBPAI firstly underwent multiple nerve transfers,which including accessory nerve transfers to neurotize the suprascapular nerve to recover the shoulder abduction,contralateral C7 (CC7) nerve transfers via the modified pre-spinal route with direct coaptation to restore lower trunk function and the musculocutaneous nerve was also neurotized by the transferred CC7 nerve via a cutaneous nerve graft to restore the function of elbow flexion,as well as the phrenic nerve transfers to neurotize the posterior division of lower trunk to restore the function of elbow and finger extension.The patients with muscle recovery were selected to perform the hand function reconstruction at the second stage for restoring the active pick-up function.The patients were chosen as followcriterias:the degree of shoulder abduction attained 30°or more,the motor power of elbow,wrist,and finger flexion attained grade M4 or more,elbow and finger extension attained M3 or more.The methods of hand function reconstruction included wrist fusion and flexor carpal ulnaris opponensplasty,in addition to palmar capsulodesis of the metacarpophalangeal joint.Results The mean follow up was 41±7.7 (range,36-73 months) after the first procedure of multiple nerve transfers,the muscle strength of elbow and finger and wrist flexion attained M 4 as well as the elbow and finger extension achieved M3 or more in 10 patients,all of 10 patients achieved 40°-80°shoulder abduction.8 out of 10 patients had performed the second surgical procedure for hand functional reconstruction.6 of them had successfully recovered the active pick-up function.Conclusions The newly designed procedure of multiple nerve transfers could effectively restore the function of shoulder abduction,elbow,wrist,and finger flexion,as well as elbows and finger extension in patients with TBPAI,combined with the hand functional reconstruction,active pick-up function could be successfully reconstructed. Key words: Brachial plexus; Wounds and injuries; Spinal nerves; Phrenic nerve; Nerve transfer

Contralateral C7 Nerve Transfer with Direct Coaptation to Restore Lower Trunk Function After Traumatic Brachial Plexus Avulsion

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 a modified prespinal route and direct coaptation with the injured lower trunk is presented here. Contralateral C7 nerve transfer via the modified prespinal route and direct coaptation with the injured lower trunk was performed in seventy-five patients with total brachial plexus avulsion injury. Thirty-five required humeral shortening osteotomy (3 to 4.5 cm) in order to accomplish the direct coaptation. The contralateral C7 nerve was also transferred to the musculocutaneous nerve through the bridging medial antebrachial cutaneous nerve arising from the lower trunk in forty-seven of the seventy-five patients. Recovery of finger, wrist, and elbow flexion was evaluated with use of the modified British Medical Research Council muscle grading system. The mean follow-up period (and standard deviation) was 57 ± 6 months (range, forty-eight to seventy-eight 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. Contralateral C7 nerve transfer via a modified prespinal route and direct coaptation with the injured lower trunk decreases the distance for nerve regeneration in patients with total brachial plexus avulsion injury. There was satisfactory recovery of finger flexion and wrist flexion in this series. In addition, contralateral C7 nerve transfer was successfully used to repair two different target nerves: the lower trunk and the musculocutaneous nerve.

Changes of inter-hemispheric functional connectivity between motor cortices after brachial plexuses injury: A resting-state fMRI study

ObjectThe aim of this study is to explore the changes of inter-hemispheric functional connectivity in patients with unilateral brachial plexus injury. MethodsNine patients with five roots of unilateral brachial plexus avulsion injury and 11 healthy controls were recruited in this study. Resting-state functional connectivity magnetic resonance image was used to study the differences of inter-hemispheric functional connectivity between patients and healthy controls. Four areas were defined as regions of interest (ROI): the two primary motor areas (M1 areas) and two supplementary motor areas (SMAs) in the two hemispheres activated when the healthy controls performed unilateral hand grasping movement of the two hands, respectively. Functional connectivity maps were generated by correlating the regional time course of each ROI with that of every voxel in the whole brain. Then, functional connectivity was calculated by correlating the functional magnetic resonance image signal time courses of every two ROIs. ResultsResting-state inter-hemispheric functional connectivity of the primary motor areas was reduced following brachial plexus avulsion injury. The correlation coefficients of the SMAs showed no difference between the brachial plexus patients and healthy volunteers. ConclusionsOur results indicate that brachial plexus injury decreases resting-state inter-hemispheric functional connectivity of the two primary motor areas. These results provide new insight into functional reorganization of the cerebral cortex after brachial plexus injury.

Cervical spinal cord stimulation for neuropathic pain after brachial plexus avulsion injury: case report

Brachial plexus avulsion is a rare and debilitating condition frequently associated with severe, intractable neuropathic pain. Treatment modalities include dorsal root entry zone lesioning, stellate ganglion blockade, and neuromodulation. We present a case of a 42 year old female with left upper extremity brachial plexopathy and complex regional pain syndrome (CRPS) type 2 following a motor vehicle accident. Her pain report consisted of constant “crushing” pain, radiating from the left shoulder into her entire left upper extremity. Additionally, she reported muscle spasms, and constant sensations of burning, numbness, and tingling. On physical examination, she presented with gross atrophy from the left shoulder girdle distally. Motor control was limited to trace movements in her distal 4th and 5th digits. She exhibited increased temperature of > 3°C; localized swelling; and violaceous color tone as compared to her unaffected limb. Palpation to light touch revealed allodynia and hyperalgesia. MRI of the cervical spine was negative for obvious spinal cord or root pathology. MRI of her brachial plexus was unremarkable; however, electrophysiologic studies demonstrated upper and middle trunk lesions. Previous unsuccessful interventions included repeated stellate ganglion blockade, transcutaneous electrical nerve stimulation (TENS), and opioid medication. Present pain medications included Gralise® 600 mg TID, tramadol 50 mg PRN, and baclofen 10 mg BID. On these medications, her average pain level was consistently 9/10. After a successful trial of cervical spinal cord stimulator leads, she went on to an uneventful permanent implantation procedure. The left and right leads were positioned with their cephalad-most contacts at the C2-3 and C4-5 levels respectively. At two-week follow up her mood and sleep were both 90% improved and her average pain report decreased to 1/10. Spinal cord stimulation is an effective treatment for neuropathic pain secondary to brachial plexopathy refractory to pharmacotherapy and conventional interventional attempts to modulate pain.

Activation of Astrocytes and Microglia in the C3–T4 Dorsal Horn by Lower Trunk Avulsion in a Rat Model of Neuropathic Pain

Brachial plexus pain is thought to be generated not by avulsed roots but rather by nonavulsed roots, because avulsed roots could not transmit action potentials to central nerves. The aim of this study was to evaluate pain-related behavior and the extent of glial activation in a model of brachial plexus avulsion (BPA). We used 24 male Wistar rats. For rats in the BPA group, the C8-T1 roots were avulsed from the spinal cord at the level of the lower trunk (n = 10). Rats in a sham-surgery group had a similar surgery without the root avulsion (n = 7). Rats in an untreated group had no surgery (n = 7). Mechanical hyperalgesia of the forelimb plantar surfaces corresponding to C6 and C7 dermatomes was evaluated using a Semmes-Weinstein monofilament test every third day for 3 weeks (n = 15). Activation of astrocytes and microglia was examined immunohistochemically using anti-glia fibrillary acidic protein and anti-Iba1 antibodies 3 days after surgery (n = 9). When compared with rats in the sham-surgery and naive control groups, rats in the BPA group displayed significant mechanical hyperalgesia in the dermatome innervated by uninjured nerves both ipsilaterally and contralaterally and continuing through day 21. Iba1-immunoreactive microglia and glia fibrillary acidic protein-immunoreactive astrocytes were significantly activated on the ipsilateral side in the BPA group from levels C3 to T3 compared with the sham-surgery and untreated groups of rats. Activation of glia at uninjured levels of the dorsal horn may facilitate pain transmission following BPA injury. Consequently, spared spinal glial cells may represent therapeutic targets for treatment of pain related to BPA injury. Our findings may indicate why neuropathic pain is so frequent and intense following BPA injury.

Expression of activating transcription factor 3 (ATF3) in uninjured dorsal root ganglion neurons in a lower trunk avulsion pain model in rats

Clinically, neuropathic pain is frequent and intense following brachial plexus injury. It is thought that brachial plexus pain is not generated by avulsed roots, but rather by non-avulsed roots, since the avulsed root could not possibly transmit action potentials to central nerves. The aim of this study was to evaluate pain behavior and activation of sensory neurons in a brachial plexus avulsion (BPA) model in rats. Fifteen male Wistar rats were used. In the BPA group, the C8-T1 roots were avulsed from the spinal cord with forceps at the lower trunk level (n = 5). In the naïve group, rats did not receive any procedures (n = 5). In the sham-operated group, the lower trunk was simply exposed (n = 5). Mechanical hyperalgesia of forelimbs corresponding to C6 and C7 dermatomes was measured using von Frey filaments every third day for 3 weeks. Activation of DRG neurons was immunohistochemically examined using anti-ATF3 (a marker for neuron activation) antibodies 21 days after surgery. Von Frey and immunohistochemical data between groups were analyzed using a Kruskal-Wallis test, followed by Mann-Whitney U tests. Bonferroni corrections were performed. Animals in the BPA group displayed significant mechanical hyperalgesia at the dermatome innervated by uninjured nerves continuing through day 21 compared with animals in the sham-operated group. ATF3-immunoreactive small and large DRG neurons were significantly activated in the BPA group (10.6 ± 9.5 and 5.2 ± 4.1 %, 39.7 ± 6.7 and 25.2 ± 10.3 %, 78.0 ± 9.1 and 53.7 ± 29.3 %) compared with the sham-operated group (0.7 ± 0.9 and 0 ± 0 %, 2.8 ± 2.0 and 1.0 ± 2.0 %, 3.9 ± 2.7 and 8.6 ± 10.1 %) at every level of C5, 6, and 7. In the naïve group, no DRG neurons were activated. ATF3-immunoreactive small and large DRG neurons were significantly activated at the level of C7 compared with C6 and C5, and significantly activated at the level of C6 compared with C5 in the BPA group. Expression of ATF3 in uninjured DRG neurons may contribute to pain following brachial plexus avulsion injury. Consequently, spared spinal sensory nerves may represent therapeutic targets for treatment of this pain.

Long-term ongoing cortical remodeling after contralateral C-7 nerve transfer

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. 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 MRI studies were used for the investigation of long-term cerebral plasticity. 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. 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.

Comparative study of phrenic nerve transfers with and without nerve graft for elbow flexion after global brachial plexus injury

BackgroundNerve transfer is a valuable surgical technique in peripheral nerve reconstruction, especially in brachial plexus injuries. Phrenic nerve transfer for elbow flexion was proved to be one of the optimal procedures in the treatment of brachial plexus injuries in the study of Gu et al. ObjectiveThe aim of this study was to compare phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury. MethodsA retrospective review of 33 patients treated with phrenic nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. All the 33 patients were confirmed to have global root avulsion brachial plexus injury by preoperative and intraoperative electromyography (EMG), physical examination and especially by intraoperative exploration. There were two types of phrenic nerve transfers: type1 – the phrenic nerve to anterolateral bundle of anterior division of upper trunk (14 patients); type 2 – the phrenic nerve via nerve graft to anterolateral bundle of musculocutaneous nerve (19 patients). Motor function and EMG evaluation were performed at least 3 years after surgery. ResultsThe efficiency of motor function in type 1 was 86%, while it was 84% in type 2. The two groups were not statistically different in terms of Medical Research Council (MRC) grade (p=1.000) and EMG results (p=1.000). There were seven patients with more than 4 month's delay of surgery, among whom only three patients regained biceps power to M3 strength or above (43%). A total of 26 patients had reconstruction done within 4 months, among whom 25 patients recovered to M3 strength or above (96%). There was a statistically significant difference of motor function between the delay of surgery within 4 months and more than 4 months (p=0.008). ConclusionPhrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury had no significant difference for biceps reinnervation according to MRC grading and EMG. A delay of the surgery after the 4 months might imply a bad prognosis for the recovery of the function.

Experience with 25 years of dorsal root entry zone lesioning at a single institution

Background:The authors sought to assess long-term efficacy, surgical morbidity, and postoperative quality of life in patients who have undergone dorsal root entry zone (DREZ) lesioning.Methods:We utilized the electronic chart system at our institution to identify patients who underwent DREZ lesioning since 1986. Of the patients that were able to be identified, 19 (12 males and 7 females) patients were able to be contacted at time of data collection. The mean age was 47 years (ranging from 23 to 70 years) with average preoperative pain duration of 12.5 years and average follow-up of 4.9 years.Results:Of the 19 patients we were able to contact, 7 (37%) patients experienced “excellent” postoperative (complete) pain relief with another 6 (32%) reporting “good” improvement. Three (16%) patients reported “mild” pain relief, while three (16%) patients reported poor results. Sixteen patients (84%) stated they would undergo DREZ lesioning again, if given a choice. Two patients (11%) had objective evidence of a new, mild motor deficit postoperatively. More than half of the patients, who answered, reported “good” quality of life. Two-sample unequal variance t-test showed no statistically significant difference in pain improvement between brachial plexus avulsion and end-zone spinal cord injury pain.Conclusion:With appropriate patient selection, DREZ lesioning is an efficacious and durable procedure that can be performed with low morbidity and good patient outcomes.

Outcome after transfer of intercostal nerves to the nerve of triceps long head in 25 adult patients with total brachial plexus root avulsion injury

The intercostal nerves (ICNs) have been used to repair the triceps branch in some organizations in the world, but the reported results differ significantly. The effect of this procedure requires evaluation. Thus, this study aimed to evaluate the outcome of ICN transfer to the nerve of the long head of the triceps muscle and to determine the factors affecting the outcome of this procedure. A retrospective review was conducted in 25 patients with global root avulsion brachial plexus injuries who underwent ICN transfer. The nerves of the long head of the triceps were the recipient nerves in all patients. The ICNs were used in 2 different ways: 2 ICNs were used as donor nerves in 18 patients, and 3 ICNs were used in 7 patients. The mean follow-up period was 5.6 years. The effective rate of motor recovery in the 25 patients was 56% for the function of the long head of the triceps. There was no significant difference in functional recovery between the patients with 2 or 3 ICN transfers. The outcome of this procedure was not altered if combined with phrenic nerve transfer to the biceps branch. Patients in whom surgery was delayed 6 months or less achieved better results. The transfer of ICNs to the nerve of long head of the triceps is an effective procedure for treating global brachial plexus avulsion injuries, even if combined with phrenic nerve transfer to the biceps branch. Two ICNs appear to be sufficient for donation. The earlier the surgery is performed, the better are the results achieved.

Patient Specific Functional Scale: Establishment of Validity in Patients with Upper Extremity Nerve Injury: Level 3 Evidence

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Long-term results of thenar muscle reanimation after contralateral C7 root transfer in repair of total brachial plexus avulsion injury

Objective To evaluate the long-term functional recovery of thenar muscles following contralateral C7 transfer in total brachial plexus root avulsion injuries. Methods Five patients treated with contralateral C7 transfer to the median nerve for brachial plexus root avulsion were follow-up for 24 to 118 months.Affected limb function,electrophysiologic evidence of recovery and the motor and sensory function of the recipient nerves in the affected limb were evaluated. Results Varied degrees of functional restorations were achieved in these 5 patients ( 2 children and 3 adults).The strength of abductor pollicis brevis (APB) muscle was M2 in four patients and M1 in one patient.The incomplete interference pattem in the APB muscle was detected by electromyogram (EMG) in two patients,while few motor unit potential (MUP) was detected in three patients.Sensory recovery reached S3 in 4 cases and S2 in one case. Conclusion Contralateral C7 nerve root transfer to the median nerve can result in thenar muscle reinnervation to certain extent in patients with brachial plexus total avulsions. Key words: Brachial plexus; Nerve transfer; Follow-up studies; Thenar muscle; Root avulsion

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

Phrenic nerve transfer (PNT) or multiple intercostal nerve transfer (MIT) alone are reported to have no significant impact on pulmonary function in the short or medium term, but it has rarely been reported whether the combination of PNT-MIT could influence respiratory function in the long term. Respiratory function was evaluated after PNT and PNT-MIT 7 to 19 years (mean, 10 years) postoperatively. Twenty-three adult patients with brachial plexus avulsion injuries who underwent PNT-MIT were compared with 19 corresponding patients who underwent PNT. Pulmonary function testings, phrenic nerve conduction study, and chest fluoroscopy were performed. In the PNT-MIT group, further investigation was performed on the effect of the number of transferred intercostal nerves and the timing of MIT. In the PNT-MIT group, forced vital capacity, forced expiratory volume in one second, and total lung capacity were 73.69%, 72.04%, and 74.81% of predicted values without significant differences from the PNT group. Diaphragmatic paralysis permanently existed with 1 to 1.5 intercostal spaces (ICSs) elevation and near 1 ICS reduced excursion. There was no statistical difference between the PNT and PNT-MIT groups. Furthermore, 3 and 4 intercostal nerves transferred resulted in no further decrease in pulmonary function test results than 2 intercostal nerves. No significant difference was found when PNT and MIT were performed at the same stage or with an interval. PNT-MIT did not result in additional impairment in respiratory function in adult patients compared with PNT alone. It is safe to transfer 2 to 4 intercostal nerves at 1 to 2 months delay after PNT.

Reinnervation of thenar muscle after repair of total brachial plexus avulsion injury with contralateral C7 root transfer: report of five cases

Reinnervation of thenar muscle after repair of total brachial plexus avulsion injury with contralateral C7 root transfer: report of five cases

Full‐length phrenic nerve transfer as the treatment for brachial plexus avulsion injury to restore wrist and finger extension

The functional restoration of wrist and finger extension after complete brachial plexus avulsion injury remains an unsolved problem. We conducted a prospective study to elucidate a new method for resolving this injury. Six patients with complete brachial plexus avulsion injury underwent a new surgical procedure in which the full-length phrenic nerve was transferred to the medial portion of the radial nerve at the level of the latissimus dorsi insertion via endoscopic thoracic surgery. In 5 patients, extensor carpi ulnaris and extensor carpi radialis strength recovered to Medical Research Council grade ≥M3, and in 4 patients extensor digitorum strength recovered to ≥M3. Neurotization of phrenic nerve to the medial portion of the radial nerve at the level of latissimus dorsi insertion is a feasible means of restoring wrist and finger extension in cases of complete brachial plexus avulsion injury.

Contralateral C7 nerve root transfer to neurotize the upper trunk via a modified prespinal route in repair of brachial plexus avulsion injury

In this report, we present our experience on the repair of brachial plexus root avulsion injuries with the use of contralateral C7 nerve root transfers with nerve grafting through a modified prespinal route. The outcomes of the contralateral C7 nerve root transfer to neurotize the upper trunk and C5/C6 nerve roots of the total or near total brachial plexus nerve root avulsion injury in a series of 41 patients were evaluated. The contralateral C7 nerve root that was dissected to the distal end of the divisions, along with the sural nerve graft, were placed underneath the anterior scalene and longus colli muscles, and then passed through the retro-esophageal space to neurotize the recipient nerve. The mean length of the dissected contralateral C7 nerve root was 6.5 ± 0.7 cm, and the mean length of sural nerve graft was 6.8 ± 1.9 cm. The suprascapular nerve was neurotized additionally by the phrenic nerve or the terminal motor branch of accessory nerve in some patients. The mean length of the follow-up was 47.2 ± 14.5 months. The muscle strength was graded M4 or M3 for the biceps muscle in 85.4% of patients, for the deltoid muscle in 82.9% of patients, and for the upper parts of pectoral major in 92.7% of patients. The functional recovery of shoulder abduction in the patients with the additional suprascapular nerve neurotization was remarkably improved. The modified prespinal route could significantly reduced the length of nerve graft in the contralateral C7 nerve root transfer to the injured upper trunk in brachial plexus root avulsion injury, and it may improve the functional outcomes, which deserves further investigations.