C5 Root Avulsion Research Articles

Insights into the Medial Pectoral Nerve Transfer for Shoulder Abduction in Brachial Plexus Injuries: A Retrospective Case Series Analysis

Treatment priority in C5, C6, and C7 brachial plexus root avulsion is the recovery of shoulder function through reinnervation of shoulder muscles. The medial pectoral nerve is a potential donor for axillary nerve transfer, but outcomes are sparsely reported. This study reports the results of medial pectoral nerve transfer to the axillary nerve. We conducted a retrospective analysis of 12 patients with traumatic brachial plexus injury (C5, C6, and C7 root avulsion) who underwent medial pectoral nerve transfer to the axillary nerve. Sociodemographic and clinical characteristics, including electromyography findings, were documented. We assessed postoperative shoulder abduction strength and range of motion. Statistical analyses compared presurgery and postsurgery outcomes and contrasted our results with those from a study using spinal accessory nerve transfer to the suprascapular nerve. Postsurgery, the mean shoulder abduction range of motion was 65.45°, with a median strength of M2. Significant improvement was noted compared to preoperative values. However, outcomes did not significantly surpass those from spinal accessory nerve transfer. Electromyography showed a low incidence of motor unit action potentials in the deltoid. Medial pectoral nerve transfer to the axillary nerve did not yield superior results in shoulder abduction and deltoid reinnervation in our group of patients. At present, different nerve donors may also need to be considered for deltoid muscle reinnervation in patients with C5, C6, and C7 root avulsion to achieve better shoulder abduction recovery.

Implications of median sensory study to the thumb and deltoid/biceps motor unit recruitment on identifying C6 root avulsion in upper neonatal brachial plexus palsy.

Anatomic representation suggests that a median sensory nerve conduction study recording the thumb (median D1 NCS) may effectively assess upper neonatal brachial plexus palsy (NBPP). We sought to determine the feasibility of technique, establish reference data, and assess its ability to: (a) identify focal upper plexus lesions; and (b) identify C6 root avulsion. In a secondary analysis, we explored the association between absence/presence of motor unit action potentials (MUAPs) during needle electromyography (EMG) of the deltoid and biceps brachii muscles and C6 avulsion status. A retrospective chart review was performed of surgical patients with severe upper NBPP who ultimately underwent surgical reconstruction (between 2017 and 2020). Median D1 sensory nerve action potential (SNAP) amplitude ranges were determined in affected and contralateral limbs and analyzed by C6 root avulsion status. Also, presence/absence of MUAPs during EMG of the deltoid and biceps brachii was compared between C6 avulsion patients and controls. Thirty-eight patients were included in our analysis. A median D1 NCS study was readily performed, showing a contralateral limb mean amplitude of 27.42 μV (range, 3.8-54.7μV). Most patients had a low ipsilateral median D1 SNAP amplitude, regardless of C6 avulsion status. Detectable MUAPs in either deltoid or biceps brachii on EMG were atypical in C6 root avulsion. The median D1 NCS identifies upper NBPP, but does not distinguish C6 avulsions from post-ganglionic lesions, likely due to the frequent co-occurrence of post-ganglionic axonal disruption. The presence of MUAPs on deltoid/biceps brachii EMG suggests C6 avulsion is unlikely.

Long-term functional recovery in C5-C6 avulsions treated with distal nerve transfers

ABSTRACT Background In patients suffering from traction lesions of the brachial plexus, complete C5 and/or C6 root avulsion patients with C7 root preservation are relatively uncommon occurrences, but represent excellent candidates for surgical treatment, with satisfactory results. Shoulder abduction and extra-rotation, elbow flexion and forearm supination are lost functions restorable with surgical treatment. Methods This single-center, prospective observational study involved a series of 27 young adults with C5 and/or C6 root complete avulsion and C7 preservation, which underwent surgical repair with double or triple nerve transfer. Results Patients recovered a useful elbow flexion. Electromyographic and clinical signs of biceps reinnervation were observed in each UN-MC nerve transfer. The abduction strength recovery was M5 in 10 patients, M4 in 14 patients and M3 in 3 patients. The external rotation strength recovery was M5 in 4 patients, M4 in 18 patients, M3 in 3 patients and M2 in 2 patients. The elbow flection strength was M5 in 5 patients, M4 in 15 patients and M3 in 7 patients. Elbow extension was preserved in all cases. Conclusions The concept of ‘peripheral rewiring procedures’ represents an advance in the repair of the peripheral nerve injuries. Triple nerve transfer can be nowadays considered a standard treatment for isolated C5-C6 avulsions. We report our experience with the second-biggest casuistry in the literature on patients treated with this technique. We consider our outcome concerning functional recovery to be satisfying and comparable to data reported in the literature.

Transfer of the phrenic nerve to musculocutaneous nerve via sural nerve graft after total brachial plexus injury

A middle age male presented a right total brachial plexus injury after motorcycle fall one year ago. Subsequent electromyographic evaluation was consistent withC5, C6, C7, C8 and T1 root avulsion. The patient was submitted to a right transfer of thephrenic nerve to musculocutaneous nerve , using rural nerve graft.

Transfer of the rhomboid nerve for restoration of shoulder external rotation in partial brachial plexus palsy

Restoration of shoulder external rotation in partial brachial plexus palsies is a real challenge. The transfer of the spinal accessory nerve to the suprascapular nerve remains the gold standard. This transfer, however, cannot be always performed. Therefore, in these cases, we previously proposed the transfer of the rhomboid nerve to the suprascapular nerve through a posterior approach. The goal of the present study is to assess this technique through a short series.Eight male patients had a partial plexus palsy. Five patients had C5, C6 root injuries, two patients had C5, C6, C7 root injuries, and one patient had C5 to C8 root injuries. No patients had C5 or C6 root avulsions. In one patient, the spinal accessory nerve was injured and in seven patients, the proximal suprascapular nerve was not available. All patients underwent a transfer from the rhomboid nerve to the suprascapular nerve. Concerning shoulder elevation, transfers from the branch of the long head of the triceps or ulnar nerve fascicle were transferred to the axillary nerve. For elbow flexion, fascicles from the ulnar nerve, median nerve, or both were used. For elbow extension, three intercostal nerves in one patient and one fascicle from the ulnar nerve in two patients were transferred to the branch of the long head of the triceps. For wrist and finger extension, palliative surgery was proposed.All patients recovered external shoulder rotation (from 70–110º) and shoulder elevation (range, 80–140º). Active elbow flexion was coded M4 in seven patients and M3 in one patient. All patients recovered active elbow extension.The transfer of the rhomboid nerve to the suprascapular nerve is an efficient procedure for shoulder external rotation in partial brachial plexus palsies without C5 root avulsion. The results in terms of range-of-motion are, however, poorer than with the spinal accessory nerve. Therefore, this technique is appropriate if the spinal accessory nerve is injured or if the suprascapular nerve is not available in the cervical area. This technique must be associated with another transfer to the axillary nerve for shoulder elevation. The study of more patients will be necessary to confirm these results.

Results of Distal Nerve Transfers in Restoration of Shoulder Function in C5 and C6 Root Avulsion Injury to the Brachial Plexus

Background The lack of shoulder function following brachial plexus injury is a debilitating condition. Nerve root avulsion injury precludes a direct nerve repair. Under these circumstances, distal nerve transfer is a well-established technique in the restoration of shoulder abduction and external rotation. Methods Thirty patients with C5 and C6 root avulsion injury were treated with distal nerve transfers in the period between February 2009 and December 2012.The average denervation period was 5.6 months. Shoulder function was restored by posterior transfer of distal part of the spinal accessory nerve into the suprascapular nerve and transfer of the long head triceps branch of radial nerve to the anterior branch of axillary nerve. An additional nerve transfer was performed in four patients with winged scapula by transferring a part of thoracodorsal nerve into the long thoracic nerve. Results Twenty-seven patients recovered shoulder abduction; 18 scored M4 and 9 scored M3. Range of abduction averaged 118 degrees (range, 90–170 degrees). Nineteen patients restored external rotation with an average of 53 degrees (range: 30–70 degrees). Three patients failed to recover shoulder abduction though the joint regained stability. External rotation remained severely restricted in 11 patients. At final follow-up, winging of scapula improved in three of four patients following reinnervation of the serratus anterior muscle. Conclusion Nerve transfers, when performed close to the target muscles, restore good range and strength of shoulder abduction in most patients with C5 and C6 root avulsion injuries. However, return in external rotation is not as good as the recovery in abduction.

Pseudomeningocele as a result of traumatic nerve root avulsion

A 23-year-old man presented with weakness of shoulder abduction and elbow flexion on the right side, with numbness of the index finger and thumb, after a bike accident. On examination, he had grade II/V power of the deltoid and biceps, with absent biceps jerk and sensory impairment in the C5–C6 dermatomes. Considering a traumatic cervical radiculopathy or brachial plexus injury, magnetic resonance imaging of the cervical spine and brachial plexus was taken, which showed cerebrospinal fluid collection lateral to the spinal cord and extending to the neural foramina, with denervation changes in the right paraspinal muscles, such as the multifidus muscle, suggestive of C6 root avulsion with pseudomeningocele (Fig. 1a,b). Pseudomeningocele is an extravasated collection of extradural cerebrospinal fluid that results from a dural tear, which unlike true meningocele, is not lined by arachnoid cells. Traumatic pseudomeningocele occurs after injuries to the brachial or lumbosacral plexus. Magnetic resonance imaging is the diagnostic modality of choice, which shows cerebrospinal fluid density adjacent to and in connection with the thecal sac.1 The prognosis of this type of nerve injury is poor. Nerve transfer techniques using spinal accessory or intercostal nerves are effective in such cases.2 The authors declare no conflict of interest.

Isolated C5–C6 avulsion in obstetric brachial plexus palsy treated by ipsilateral C7 neurotization to the upper trunk: outcomes at a mean follow-up of 9 years

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5-C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5-C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5-C6 nerve root avulsion.

Intraplexal nerve transfers

Intraplexal nerve transfer is defined as nerve transfer of a nerve within the brachial plexus with intact spinal cord connections to a more important injured nerve. For elbow flexion, the most popular one for the upper arm brachial plexus injury is the “Oberlin” nerve transfer. Transferring a part of the ulnar nerve to the branch to the biceps (Oberlin 1) and possibly transferring a part of the median nerve to the branch to the brachialis (Oberlin 2) provides promising results for elbow flexion without any permanent deficit of the donor nerve function. In 1998, we published the paper using the Oberlin 1 technique in 32 cases with upper arm brachial plexus injury. Thirty patients had biceps strength of M4 (flexion power ranged from 0.5 to 7 kg) and 1 had biceps strength of M3. All but 1 patient demonstrated signs of recovery of the biceps muscle. No notable impairment of hand function was observed. For shoulder abduction, most nerve surgeons recommended nerve transfers both to the suprascapular nerve and the axillary nerve. In 2003, we described the nerve transfer to the deltoid muscle using the nerve to the long head of triceps both anatomically and clinically in 7 cases. All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124 degrees. No notable weakness of elbow extension was observed. In 2006, we published the paper of combined nerve transfers for C5 and C6 brachial plexus avulsion injury in 15 cases. All 15 patients achieved useful functional recovery. Ten patients experienced excellent recoveries and 5 were classified as having good results. The mean shoulder abduction was 115°. The mean shoulder external rotation was 97°. No patients complained of functional deficit from harvesting of the nerve to the long head of the triceps. In our experience, 40 % of our patients with upper arm typed brachial plexus injury demonstrated winged scapula from serratus anterior weakness. In 2009, we described the nerve transfer to serratus anterior muscle using the thoracodorsal nerve in C5 and C6 brachial plexus avulsion injury in 5 patients. All patients recovered serratus anterior muscle function. Two patients had no winged scapula, whereas 3 patients had mild winged scapula after the surgery at the last follow-up evaluation. The result was excellent for 2 patients, good for 2 patients, and fair for 1 patient. The averaged shoulder abduction was increased to 134 degrees and external rotation was 124 degree. No notable weakness of shoulder adduction was observed. For wrist extension in C5, C6 and C7 brachial plexus injury which is difficult to achieve by tendon transfer, we described the nerve transfer using the branch of median nerve to restore the wrist extension. We used Flexor digitorumsuperficialis branch of median nerve transfer to extensor carpi radialis branch of radial nerve. This technique could restore wrist extension in C5, C6 and C7 brachial plexus root avulsion.

Nerve transfers for brachial neuralgia

Motor function, rather than sensory function, is the primary concern for most brachial plexus surgeons. After root avulsions from the spinal cord, numbness in the affected limb may be associated with extreme, almost unbearable, intractable pain. Deafferent pain is the result of avulsion of the root from the spinal cord. Pain from the brachial plexus avulsion probably arises from the disinhibition of neurons within the substantia gelatinosa that fire spontaneously. The convulsive pain of the brachial plexus injury may correlate with the burst pattern of firing in lamina V also observed in higher levels of the central nervous system including the thalamus. It has been postulated that the lack of sensory input into the spinal cord leads to spontaneous discharges of the neurons in the dorsal horn, therebycausing pain. In our experience, one-third of patients with C5 and C6 root avulsion presented with pain on the dorsal radial aspect of the hand correlated with the superficial radial nerve distribution. Nerve transfer may inhibit abnormal electrical activity in the dorsal horn or higher levels of the central nervous system such as the thalamus by restoring the input to the damaged limb. In 2011 we described the technique “End-to-Side Radial Sensory to Median Nerve Transfer to Restore Sensation and Relieve Pain in C5 and C6Nerve Root Avulsion” in 8 patients. Six patients had S2 and 2 patients had S3. All patients perceived at least one number lower of the Semmes-Weinstein filament in the dorsal radial aspect of the affected hand compared with the preoperative status. The best result was perception of the 3.61 filament in 2 patients. No downgrading of the donor nerve was observed after surgery. All patients had relief of pain 2 weeks after surgery, and the pain decreased dramatically at the last follow-up. An interesting finding in our patients is that we observed no cross-misperception between the injured nerve and donor nerve territories. One hypothesis is that the induced collateral axons are specifically aimed to their new target reconnecting with the spinal cord neurons; another explanation is that there is an unknown mechanism of brain plasticity. Recently, we performed end-to-side median nerve into contralateral C7 transfer to relieve pain at the median nerve distribution area of the hand in late total arm type brachial plexus injury in 7 patients. All patients perceived at least 2 number lower of the Visual Analog Scale (VAS) for pain at the median nerve distribution area of the affected hand and at least 20% decrease in the PSRS compared with the preoperative status. The mean VAS was decreased from 7.8 to 4.1 and the mean PSRS was decrease from 28.4 to 17.5 at last F/U. No downgrading of the donor nerve was observed after surgery. None of the patients experienced any major complication. This nerve transfer could be an alternative method to treat refractory deafferent pain in total arm type brachial plexus injury without major complications.

Human amniotic epithelial cell transplantation for the repair of injured brachial plexus nerve: evaluation of nerve viscoelastic properties.

The transplantation of embryonic stem cells can effectively improve the creeping strength of nerves near an injury site in animals. Amniotic epithelial cells have similar biological properties as embryonic stem cells; therefore, we hypothesized that transplantation of amniotic epithelial cells can repair peripheral nerve injury and recover the creeping strength of the brachial plexus nerve. In the present study, a brachial plexus injury model was established in rabbits using the C6 root avulsion method. A suspension of human amniotic epithelial cells was repeatedly injected over an area 4.0 mm lateral to the cephal and caudal ends of the C6 brachial plexus injury site (1 × 106 cells/mL, 3 μL/injection, 25 injections) immediately after the injury. The results showed that the decrease in stress and increase in strain at 7,200 seconds in the injured rabbit C6 brachial plexus nerve were mitigated by the cell transplantation, restoring the viscoelastic stress relaxation and creep properties of the brachial plexus nerve. The forepaw functions were also significantly improved at 26 weeks after injury. These data indicate that transplantation of human amniotic epithelial cells can effectively restore the mechanical properties of the brachial plexus nerve after injury in rabbits and that viscoelasticity may be an important index for the evaluation of brachial plexus injury in animals.

Simultaneous Intercostal Nerve Transfers to Deltoid and Triceps Muscle Through the Posterior Approach

This study reports the results of restoring the deltoid and triceps functions in patients with C5, C6, and C7 root avulsion injuries by simultaneously transferring 4 intercostal nerves to the anterior axillary nerve and the nerve to the long head of the triceps through the posterior approach. Nine patients with C5, C6, and C7 root avulsion injuries underwent spinal accessory nerve transfer to the suprascapular nerve combined with transfer of the third and fourth intercostal nerves to the anterior axillary nerve for shoulder reconstruction. Simultaneous transfer of the fifth and sixth intercostal nerves to the radial nerve branch of the triceps was done to restore elbow extension. For shoulder function, 8 patients had M4 recovery and 1 patient had M2 recovery. Average shoulder abduction and external rotation were 69° and 42°, respectively. For elbow extension, 3 patients achieved M3 recovery, 5 patients had M2 recovery, and 1 patient had M1 recovery. Reconstruction of 2 muscles with intercostal nerves is possible when both muscles act synergistically, such as shoulder abduction and elbow extension. Two intercostal nerves are adequate to transfer for deltoid reconstruction but not enough for elbow extension against gravity. Therapeutic IV.

Computer Simulation of Nerve Transfer Strategies for Restoring Shoulder Function After Adult C5 and C6 Root Avulsion Injuries

Functional ability after nerve transfer for upper brachial plexus injuries relies on both the function and magnitude of force recovery of targeted muscles. Following nerve transfers targeting either the axillary nerve, suprascapular nerve, or both, it is unclear whether functional ability is restored in the face of limited muscle force recovery. We used a computer model to simulate flexing the elbow while maintaining a functional shoulder posture for 3 nerve transfer scenarios. We assessed the minimum restored force capacity necessary to perform the task, the associated compensations by neighboring muscles, and the effect of altered muscle coordination on movement effort. The minimum force restored by the axillary, suprascapular, and combined nerve transfers that was required for the model to simulate the desired movement was 25%, 40%, and 15% of the unimpaired muscle force capacity, respectively. When the deltoid was paralyzed, the infraspinatus and subscapularis muscles generated higher shoulder abduction moments to compensate for deltoid weakness. For all scenarios, movement effort increased as restored force capacity decreased. Combined axillary and suprascapular nerve transfer required the least restored force capacity to perform the desired elbow flexion task, whereas single suprascapular nerve transfer required the most restored force capacity to perform the same task. Although compensation mechanisms allowed all scenarios to perform the desired movement despite weakened shoulder muscles, compensation increased movement effort. Dynamic simulations allowed independent evaluation of the effect of restored force capacity on functional outcome in a way that is not possible experimentally. Simultaneous nerve transfer to suprascapular and axillary nerves yields the best simulated biomechanical outcome for lower magnitudes of muscle force recovery in this computer model. Axillary nerve transfer performs nearly as well as the combined transfer, whereas suprascapular nerve transfer is more sensitive to the magnitude of reinnervation and is therefore avoided.

Transfer of a Motor Fascicle From the Ulnar Nerve to the Branch of the Radial Nerve Destined to the Long Head of the Triceps for Restoration of Elbow Extension in Brachial Plexus Surgery

Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

BYPASS COAPTATION FOR CERVICAL ROOT AVULSION

Previously, we reported bypass coaptation of the C3 and C4 anterior rami to the upper trunk of the brachial plexus for restoration of the muscles denervated as a result of C5 and C6 nerve root avulsion. This procedure is thought to be superior to the transfer of individual peripheral nerve fibers to the brachial plexus branches. Therefore, the benefits of the bypass coaptation procedures in the treatment of various root avulsions are presented. Twenty-six patients were selected as suitable candidates for bypass coaptation procedures. They were divided into 3 groups: 1) Erb-Duchenne palsy due to C5 and C6 root avulsion, 2) Klumpke palsy due to C8 and T1 root avulsion, and 3) the flail arm (or flail upper limb) due to C5 through T1 root avulsion. The surgical techniques are described in detail. The coaptation procedures for the first group resulted in excellent recovery of all the denervated muscles. The patients in the second group showed reinnervation of the finger muscles and finger sensory distributions in infants within the first year after surgery. The flail arm group regained satisfactory proximal muscle function but only mild distal muscle function. One exception was a child who showed significant recovery in proximal and distal motor and sensory function. We recommend the bypass coaptation as a useful procedure for the following categories: Erb-Duchenne palsy due to C5 and C6 root avulsion in all ages, Klumpke palsy due to the C8 and T1 avulsion, and the flail arm due to C5 through T1 avulsion in young children. However, bypass procedures for the flail limb in adults require additional innovative methods to facilitate the growth rate of regenerating nerves.

The Behavioral and Immunological Effect of GM-1 Ganglioside on Nerve Root Regeneration Following C5 Nerve Root Avulsion in a Rat Model

Preganglionic nerve root avulsion precludes sensory return, but motor regeneration is possible with sparing of motoneurons. The effect of GM-1 ganglioside treatment was studied with parallel evaluation of the autoimmune response. Rats (N=64) received injections of either GM-1 ganglioside or saline for 30 days following either C5 root avulsion or a hemilaminectomy control. The Bertelli grooming test assessed functional return. Before sacrifice at 5 months, serum was collected for enzyme-linked immunoabsorbent assay testing. Only 44% of the rats treated with ganglioside had a good functional outcome compared with 50% for controls. Although 17% of the rats developed anti GM-1 antibodies, there was no functional or histological evidence of neuropathy in any of the rats. We conclude that ganglioside treatment did not enhance recovery from peripheral nerve injury. Although an immune response was present in some rats, no overt signs of neuropathy were observed.

An experimental study on outcome of ipsilateral C7 nerve root transfer to repair the root avulsion of the brachial plexus

To experimentally compare the treatment outcome of the injured upper limb of the root avulsion of C5 and C6 of the brachial plexus repaired by ipsilateral C7 nerve root transfer and other three multiple nerve transfers. One hundred and twenty SD rats of simulated C5 and C6 root avulsion randomly divided into 4 groups, and 30 each underwent various combined nerve transfers. Group A: the ipsilateral C7 root transferred to the upper trunk of brachial plexus and the spinal accessory nerve to the suprascapular nerve; Group B: partial fascicles of the ulnar nerve transferred to the biceps branch (Oberlin's procedure), the spinal accessory to the suprascapular and branches to the triceps long head to the axillary nerve; Group C: the phrenic transferred to the musculocutaneous, cervical plexus motor branches to the lower trunk (axillary nerve) of brachial plexus and the spinal accessory nerve to the suprascapular nerve; Group D: the phrenic transferred to the musculocutaneous and the spinal accessory nerve to the suprascapular nerve. Neurotization outcomes were evaluated at 3, 6 and 12 weeks postoperatively by comparing changes of behavioral tests (Ochiai clinical scores, Barth Foot-fault test and Terzis grooming test), neurophysiological investigations and muscular histology. At 3 weeks after operation, no significant difference was found between Group A and other three control groups in the three behavioral evaluations. Neurophysiologic investigations of the axillary nerve showed that Group A was superior to the other three groups. Muscular histological outcome of the axillary nerve and deltoid muscle showed that Group A was superior to the Group C and D, while no significant difference was found between Group A and B. Except that the thruput of regenerating medullated musculocutaneous nerve fibers of Group A was superior to Group C, neurophysiological and histological outcome of the musculocutaneous nerve and biceps showed that no significant difference was found between Group A and other three groups. At 12 weeks postoperatively, nearly all the behavioral, neurophysiological and histological determination showed that Group A was superior to the other three groups. Ipsilateral C7 transfer to the upper trunk of brachial plexus combined with the spinal accessory nerve to the suprascapular nerve is found to be significantly effective on treatment of the root avulsion of C5 and C6 of the brachial plexus.

Shoulder Muscle Reconstruction in the Upper Type of the Brachial Plexus Injury by Partial Radial Nerve Transfer to the Axillary Nerve

Brachial plexus palsy with upper segment C5 and C6 root avulsion can be effectively treated using a part of the radial nerve transferred to the axillary nerve. Shoulder stability and abduction was obtained with good deltoid muscle contraction. When combined with spinal accessory nerve transfer to the suprascapular nerve, the overall functional result was enhanced. Elbow flexion can be reconstructed by partial median nerve transfer to the musculocutaneous nerve. There were no neurologic deficits after nerve surgery.

Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus.

We applied a nerve transfer, using the ipsilateral C7 nerve root to treat the C5 and C6 root avulsion of the brachial plexus. Four patients with C5 and C6 preganglionic injury were operated on with this new technique from 1998-2000. Transfer of the spinal accessory nerve to the suprascapular nerve was simultaneously done in 2 these patients. After a follow-up of 1-2.5 years, the muscle strength of elbow flexors recovered to M4 (Lovett) in all cases, shoulder abduction of >90 degrees with external rotation of 30-40 degrees was gained in two cases, and that of 15-45 degrees with no external rotation in the other two cases. No remarkable impairment was found in all C7-innervated muscles except for decrease of muscle power of 1 grade (Lovett) in the short run. This new technique shows promise as an efficacious and safe treatment for C5 and C6 root avulsion of the brachial plexus. However, it should be applied prudently when incomplete injuries of the lower trunk are involved.

Nerve transfer to biceps muscle using a part of ulnar nerve for C5–C6 avulsion of the brachial plexus: Anatomical study and report of four cases

Four patients with C5–C6 root avulsion after brachial plexus injury were treated with a transfer of part of a normal functioning nerve in the arm to the motor nerve of the biceps. Ten percent of the bulk of the ulnar nerve was harvested for a suture directly to the motor nerve of the biceps with no significant impairment of hand function.