Direct Nerve Repair Research Articles

Mandibular Nerve and Lingual Nerve Injuries and Their Management Based on Aetiology, Time of Repair and Method of Intervention: A Systematic Review

Introduction: The purpose of this study was to scientifically review to determine the incidence, prevention protocols and recovery rate and reach a desirable protocol for the management of inferior alveolar nerve (IAN) injury and lingual nerve (LN) injury using the comprehensive overview of literature during various maxillofacial surgical procedures. Materials and Methods: Literature was selected through a search of PubMed, Cochrane Library and Google Scholar electronic databases. Articles from January 2010 to March 2023 were searched. All language articles with a minimum of 6-month patient follow-up and injury analysis by a patient’s reporting, radiographic and neurosensory testing were selected. Results: In total, 52 literature sources were reviewed, and 21 of the most relevant articles that are suitable to the criteria were selected. The impact of lower third molar removal (especially impacted) on the LN injury and IAN injury was clearly seen. Conclusions: Based on the study, it was clear that most injuries were occurring during removal of mandibular third molar. Thus, cone-beam computed tomography-based pre-operative analysis is a must in such cases. The results were significantly better in the early treatment group compared to the late group. Direct nerve repair without tension gives the best surgical outcome than other methods. Autogenous nerve graft was superior amongst other grafts which were used. Further studies were required to open a new paradigm for nerve repairs.

452 Leg Flexion to Overcome Gaps for Direct Sciatic Nerve Repair: An Anatomic Study

INTRODUCTION: Direct nerve repairs fare better than grafted nerves, especially for large caliber nerves. Numerous surgical techniques are used to achieve tension-free end-to-end repairs for large gaps in the sciatic nerve (SN) and common peroneal nerve (CPN), including distal nerve mobilization, transposition, side-branch neurectomy, or even shortening of the femur with distraction osteogenesis. However, leg flexion with serial distraction is the simplest, least morbid, and most easily implemented technique. METHODS: Eight fresh cadavers with pelvis intact were dissected to determine the relationship between degrees of knee flexion (ranged from 0 to 90-degree flexion) and the gap length overcome with nerve excursion. Additional excursion from SN side-branch neurectomy was also assessed. RESULTS: We found an approximately linear relationship between knee flexion and nerve excursion. In the mid-thigh there was 7-9 mm of SN excursion per 10 degrees of flexion, and 10-11 mm of SN excursion per 10 degrees of flexion with neurectomy. There was 11-13 mm of CPN excursion per 10 degrees of flexion in the distal half of the thigh. CONCLUSIONS: Knee flexion can significantly augment the ability to achieve an end-to-end repair of the SN and CPN. Simplified, each 10 degrees of knee flexion provides about 1 cm of additional length for both nerves, which is essentially constant throughout the arc of flexion. Neurectomy allows approximately 1-2 cm in total additional length at full flexion in fresh cadavers. Approximately 10 cm total excursion can be gained at 90-degree knee flexion with side-branch neurectomies. We recommend 45-90 days of progressive extension to respect the safe regeneration timing of 1-2 mm/day from a repair performed with 90-degree knee flexion.

Updates in peripheral nerve surgery of the upper extremity: diagnosis and treatment options.

The loss of function resulting from peripheral nerve injuries confers a significant burden to the patient and society. The treatment of peripheral nerve injuries requires an accurate diagnosis and formulation of a functional reconstructive plan. Advances in peripheral nerve imaging complement electrodiagnostic studies, and provide us with detailed information regarding the status of nerve injury, repair, and regeneration in order to prognosticate recovery and determine the need for surgical intervention. When direct nerve repair is not possible, the methods for bridging a nerve gap are the nerve autograft, allograft and conduit. While current research supports the use of conduits and nerve allografts for shorter nerve gaps, the nerve autograft still remains the gold standard for bridging a nerve gap. When direct nerve repair or nerve grafting fails, or is anticipated to be insufficient, nerve transfers are an alternative for reconstruction. Knowledge of axonal counts, upper limb innervation patterns, location and clustering of upper limb peripheral nerves allows for the design of new nerve transfers. The options of nerve transfers for radial, ulnar and median nerve injuries are outlined, as well as their outcomes. Nerve transfers are an attractive option for restoring motor and sensory function while minimizing donor site morbidity. However, one must consider their limitations, and preserve donor sites for secondary tendon transfer options. This article presents the latest information regarding the imaging of peripheral nerves, methods to bridge a nerve gap, and nerve transfers to aid the peripheral nerve surgeon in choosing a reconstructive plan.

Nerve Injury and Photobiomodulation, a Promising Opportunity: A Scoping Review on Laser Assisted Protocols for Lesions in the Oral Region

The currently available therapeutic options for restoring function and sensitivity in long-term nervous injuries pose challenges. Microsurgery interventions for direct nerve repair often lead to serious complications and limited success. Non-surgical methods, although somewhat effective, have limited benefits. These methods involve drug administration, such as with analgesics or corticosteroids. Photobiomodulation therapy (PBMT) has emerged as a promising approach based on clinical and laboratory studies. PBMT stimulates the migration and proliferation of neuronal fiber cellular aggregates, as reported in the literature. Experimental studies on animal models with peripheral nerve compression injuries have shown that PBMT can enhance the functionality of damaged nerves, preserving their activity and preventing scar tissue formation. The mechanism of action depends on the wavelength, which can positively or negatively affect photo acceptor resonances, influencing their conformation and activities. These findings suggest that photobiomodulation may accelerate and improve nerve regeneration. This review explores various methodologies used in photobiomodulation for regenerating nerve sensitivity after surgical trauma involving nerve structures, in the oral and peri-oral region. Research was conducted to evaluate which laser-assisted therapeutic protocols are used to improve the recovery of nervous sensitivity, using the JBI methodology for scoping reviews and following the PRISMA methodology.

TENDON TRANSFERS FOR RADIAL NERVE PALSY

The most common indication for upper extremity tendon transfer procedure is a peripheral nerve injury that has no potential to improve. Ÿ This includes nerve injuries that are irreparable such as root avulsions, nerve injuries that do not recover after direct nerve repair or grafting, or failed nerve transfers or delayed presentation. Ÿ In case of radial nerve palsy, the patient cannot extend the wrist, ngers and thumb, so has a great difculty in grasping objects

Advances of Direct Peripheral Nerve Repair Techniques: Do We Already Have Enough Scientific Evidence?

To systematically review the evidence of direct peripheral nerve repair techniques and to determine any differences in outcomes that would guide rational treatment. Additionally, we compare the results and outcomes of these studies and find future directions for peripheral nerve repair techniques. We searched PubMed, Virtual Health Library, and Embase databases to identify articles involving direct peripheral nerve techniques. We analyzed and compared the results and outcomes of these techniques. We also aimed to look for the differences in outcomes that would guide the current and future treatments. We identified 1390 articles, and 19 met our criteria with evidence ranging from level I to level IV. The nerve repair techniques included direct repair, epineural repair, fascicular repair, and group fascicular repair. These nerve techniques are based on the surgeons' personal experience. The results and the outcome of these studies were based on prognostic factors and not on surgical techniques. Few studies compared the surgical techniques and found no significant difference in nerve repair techniques. Analyzing all direct peripheral nerve techniques and literature of all levels of evidence, our data show no significant difference between different suturing techniques. Currently, there is a lack of scientific evidence on the best direct peripheral nerve repair techniques. Therefore, we need more research to understand the rational treatment methods for peripheral nerve injuries. IV.

Bioengineered nerve conduits and wraps for peripheral nerve repair of the upper limb

Bioengineered nerve conduits and wraps for peripheral nerve repair of the upper limb

Axonal Regeneration Through Autologous Grafts: Does the Axonal Load Influence Regeneration?

IntroductionTwo-stage free functional muscle transfers for long-standing facial palsy can yield unpredictable results. Earlier studies have demonstrated incomplete regeneration across neurorrhaphies in native nerve and higher donor axonal counts correlating with improved outcomes but axonal count in nerve grafts have not been as thoroughly reviewed. To investigate the impact of varying axonal counts in autologous grafts on functional outcomes of repair. Materials and methodsAnimals were allocated into three groups: Direct Nerve Repair (DNR, n = 50), Small Nerve Graft (SNG, n = 50), and Large Nerve Graft (LNG, n = 50). All grafts were inset into the Posterior Auricular Nerve with ear movement recovery (EMR) monitored as functional outcome. At various postoperative weeks (POWs), excised specimens were imaged with electron microscopy. Axonal counts were measured proximal to, distal (DAC) to, and within grafts. Total Success Ratio (TSR) was calculated. ResultsIn DNR, DAC was significantly lower than proximal axonal counts at all POWs, with maximum TSR of 80%. TSR for LNG and SNG were significantly lower at all POWs when compared to DNR, with maximums of 56% and 38%, respectively. LNG had a significantly larger DAC than SNG at POW12 and beyond. A direct relationship was present between DAC and EMR for all values. ConclusionsHigher native axonal count of autologous nerve grafts resulted in higher percentage of regeneration across neurorrhaphies.

Cold sensitivity and its association to functional disability following a major nerve trunk injury in the upper extremity-A national registry-based study.

AimsTo investigate self-reported cold sensitivity and functional disability after a repaired major nerve trunk injury in the upper extremity.MethodsWe identified 735 individuals with a major nerve trunk injury in the upper extremity, surgically treated with direct nerve repair or reconstructed with nerve autografts, in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity, and perceived disability were collected using two questionnaires (HQ-8 and QuickDASH) preoperatively, and at three and 12 months postoperatively.ResultsWe included 281 individuals, who had responded the questionnaires, where 197 (70%) were men (median age 34 [interquartile range 25–52] years) and 84 (30%) were women (median age 41 [25–55]). Cold sensitivity (scored 0–100) was the most prominent symptom 12 months postoperatively after an injured and repaired/reconstructed median (p<0.001) or ulnar (p<0.001) nerve, while individuals with a radial nerve injury showed milder symptoms. Concomitant injuries did not affect cold sensitivity scores. Individuals with ulnar nerve injuries scored higher in stiffness (p = 0.019), weakness (p<0.001) and ability to perform daily activities (p = 0.003) at 12 months postoperatively than median nerve injuries. Individuals with a median, ulnar or radial nerve injury with severe (>70) cold sensitivity had 25, 37 and 30 points higher QuickDASH scores, respectively (p<0.001), at 12 months postoperatively than individuals with mild (<30) cold sensitivity. There were no differences in QuickDASH score or cold sensitivity score at 12 months postoperatively between direct nerve repair or nerve reconstruction with nerve autografts. Neither age, nor sex, affected QuickDASH score at 12 months postoperatively.ConclusionCold sensitivity after surgery for a major nerve trunk injury in the upper extremity can be substantial with impaired ability to perform daily activities, where an ulnar nerve injury may have a worse outcome.

COMMON PERONEAL NERVE INJURIES AT THE KNEE: OUTCOMES OF NERVE REPAIR

Background. Common peroneal nerve (CPn) lesion at the knee is one of the most frequent neurologic injury of the lower limb. Among the etiologies there are also open and closed trauma. If direct nerve repair is not possible, nerve grafting is indicated as a primary or delayed procedure. Nerve and tendon transfer are other possible therapeutic options. Material and methods. In this retrospective double center study, 35 patients with post-traumatic CPn lesion at the knee, that underwent surgical repair, were analyzed. Exclusion criteria were severe concomitant neurological pathologies, complex injury of the lower leg including major vessels lesion and or tibial nerve injury. The objective of the study is to demonstrate the degree of foot dorsiflexion recovery based on the type of trauma and the corresponding performed surgery: the Medical Research Council classification (M0-M5) was used as rating scale. Results. There were 23 closed and 12 open injuries. Time of surgery varied from 6 to 11 months after closed trauma, whereas 2 open traumas were explored at emergency and the remaining 10 patients were explored 3 to 9 months after injury. Neurolysis was performed in 12 cases. Neurorraphy was performed in 2 cases. Sural nerve grafting was performed in 21 patients, with a length range of 6-10,5 cm and 4-9 cm for closed and open trauma respectively. Conclusions. Our series confirms that repairs of traumatic CPn injuries have an unfavorable outcome. Motor recovery score ≥&nbsp;M3 was obtained in only 10 cases (28,57%). Neurolysis and nerve suture show better results than nerve graft alone, although no statistically significant differences emerged; CPn reconstructions with grafts show unsatisfactory results, particularly if the length of the grafts exceeds 6 cm and when patients are treated over 6 months after the trauma. Patients with closed trauma achieve less satisfactory results than those with open injury (13 vs 58%) and this was statistically significant (p&nbsp;&lt;&nbsp;0.05), so palliative surgery may be indicated as the first surgical approach for these patients to achieve good foot dorsiflexion.

Combined distal nerve and tendon transfer in drop wrist for treatment of high injuries of the radial nerve

The aim of direct distal selective nerve transfer close to the end organ with high radial nerve injury is restoration of the paretic function before irreversible atrophy of the target muscle. Simultaneous tendon transfer enables direct functional correction of wrist drop. Selective nerve and tendon transfer of the lower arm is indicated if a)the primary nerve lesion is located proximally distant and reinnervation by direct nerve repair would take too long to reach aparetic muscle because of the long distance involved, b)direct repair of the nerve lesion is impossible or c)there has been a substantial delay after the primary injury. Aviable donor nerve must be available. A) After final denervation of amuscle, which occurs approximately 1.5years after a nerve injury, the atrophy is irreversible and a nerve transfer can no longer restore the paretic muscle. Only younger patients under 30 years old might benefit from delayed nerve transfer. B) When no sufficient donor nerve is available only tendon transfer is possible. Direct nerve transfer from the median nerve to the radial nerve as well as direct functional correction of wrist drop by tendon transfer of the pronator teres muscle. Immobilization of the arm for 3 days, wrist orthosis for 6weeks for protection of the tendon transfer, ergotherapy and physiotherapy preferably by a hand therapist. Active wrist and finger extension 2years after transfer, with individualized extension of the thumb and index finger is possible, wrist drop reversed.

Trends in Peripheral Nerve Epidemiology and Reconstruction: A State Database Study of Direct Repairs, Grafts, and Conduits.

Peripheral nerve injuries (PNIs) are most commonly treated with direct nerve repair procedures or nerve autografts. However, recent advancements in synthetic and vein conduits have led to their increased utilization. The present study quantifies the incidence of these procedures over time and geography and identifies differences in complication rates, illustrating the current epidemiologic climate regarding conduit use for PNI repair. A query was conducted using the State Ambulatory Surgery and Services Databases data from 2006 to 2011 in both Florida and California for patients undergoing nerve repair, nerve grafting, synthetic conduits, and vein conduits. Patient zip code data were analyzed to determine the geographic distribution of various types of repair. In addition, text-mining algorithms were used to identify trends in PNI-related publications. In the 6-year period investigated, direct nerve repair was the most frequently used procedure for PNIs. However, the utilization of direct repairs declined significantly from 2006 to 2011. Synthetic and vein conduits demonstrated a significant increase over the same period. There were significantly higher rates of complications for autologous grafts (3.3%), vein conduits (3.5%), and synthetic conduits (2.4%), as compared with direct nerve repairs (1.4%). There was a nonsignificant difference in infection rates between these types of nerve repair. From an epidemiologic perspective, both graft and synthetic conduit-based PNI repairs are increasing in prevalence both in clinical practice and in the academic literature. This will likely continue in the future with the development of advancements in biologic and synthetic nerve conduit PNI repair options.

Prevention and Treatment of Nerve Injuries in Shoulder Arthroplasty.

Nerve injuries during shoulder arthroplasty have traditionally been considered rare events, but recent electrodiagnostic studies have shown that intraoperative nerve trauma is relatively common. The brachial plexus and axillary and suprascapular nerves are the most commonly injured neurologic structures, with the radial and musculocutaneous nerves being less common sites of injury. Specific measures taken during the surgical approach, component implantation, and revision surgery may help to prevent direct nerve injury. Intraoperative positioning maneuvers and arm lengthening warrant consideration to minimize indirect injuries. Suspected nerve injuries should be investigated with electromyography preferably at 6 weeks and no later than 3 months postoperatively, allowing for primary reconstruction within 3 to 6 months of injury when indicated. Primary reconstructive options include neurolysis, direct nerve repair, nerve grafting, and nerve transfers. Secondary reconstruction is preferred for injuries presenting >12 months after surgery. Secondary reconstructive options with favorable outcomes include tendon transfers and free functioning muscle transfers.

Local Riluzole Release from a Thermosensitive Hydrogel Rescues Injured Motoneurons through Nerve Root Stumps in a Brachial Plexus Injury Rat Model.

The C5-C6 nerve roots are usually spared from avulsion after brachial plexus injury (BPI) and can thus be used as donors for nerve repair. A BPI rat model with C5-C6 nerve root stumps has been established in our previous work. The aim of this study was to test whether riluzole loaded into a thermosensitive hydrogel could applied locally in the nerve root stumps of this BPI rat model, thus increasing the reparative effect of the nerve root stumps. Nile red (a hydrophobic dye) was used as a substitute for riluzole since riluzole itself does not emit light. Nile red, loaded into a thermosensitive hydrogel, was added to the nerve root stumps of the BPI rat model. Additionally, eighteen rats, with operation on right brachial plexus, were evenly divided into three groups: control (Con), thermosensitive hydrogel (Gel) and thermosensitive hydrogel loaded with riluzole (Gel + Ri) groups. Direct nerve repair was performed after local riluzole release for two weeks. Functional and electrophysiological evaluations and histological assessments were used to evaluate the reparative effect 8 weeks after nerve repair. Nile red was slowly released from the thermosensitive hydrogel and retrograde transport through the nerve root stumps to the motoneurons, according to immunofluorescence. Discernible functional recovery began earlier in the Gel + Ri group. The compound muscle action potential, ChAT-expressing motoneurons, positivity for neurofilaments and S100, diameter of regenerating axons, myelin sheath thickness and density of myelinated fibers were markedly increased in the Gel + Ri group compared with the Con and Gel groups. Our results indicate that the local administration of riluzole could undergo retrograde transportation through C5-C6 nerve root stumps, thereby promoting neuroprotection and increasing nerve regeneration.

Obesity status is a risk factor for secondary surgery after neurolysis, direct nerve repair or nerve grafting in traumatic brachial plexus injury: a retrospective cohort study

BackgroundThe objective of the study was to investigate the association between obesity and the presence of secondary surgery following neurolysis, direct nerve repair, or nerve grafting in patients with traumatic brachial plexus injury.MethodsIn this retrospective chart review spanning two Level I medical centers in a single metropolitan area, 57 patients who underwent neurolysis, direct nerve repair, or nerve grafting for brachial plexus injuries between 2002 and 2015 were identified. Risk regression analysis was used to evaluate the association between obesity status and secondary surgery.ResultsAfter controlling for the confounding variables of age, high energy injury, associated shoulder dislocation and associated clavicle fracture using multivariate regression (risk regression), the risk ratio of secondary surgery in obese patients compared to non-obese patients was 6.99 (P = 0.028). The most common secondary surgery was tendon or local muscle transfer.ConclusionsThere is an increased risk of secondary surgery in obese patients compared to non-obese patients of the same age and with the same severity of injury. The increased risk may be due to challenges related to powering a heavier upper extremity. A weight reduction program might be considered as part of the preoperative strategy.

Delayed nerve repair with epineural microsutures in traumatic radial nerve palsy: a case report

Introduction: Traumatic radial nerve palsy is a condition that need surgical management. Patients who neglect their symptoms or under diagnosed on examination, cause delays to their surgery treatment. Direct nerve repair with epineural microsutures is still the gold standart of surgical treatment for severe axonotmesis and neurotmesis injuries. In this article, we reported a case of nerve repair with epineural microsutures in traumatic radial nerve palsy.Case presentation: A 14-year-old male complained cramps, tingling, and numbness of his left arm and he was unable to extend his left wrist and fingers after he got a left arm injury 3 months ago. The electromyography (EMG) shown that left radial nerve lesion at left radial sulcus. Direct nerve repair is performed by epineural microsutures. Â Two weeks after surgery, we found improvement on the sensory process, but no improvement on the motoric process.Conclusion: Direct nerve repair with epineural microsutures is an effective treatment for radial nerve injury, but the timing for surgery influencing the result of operation.

Animal models used to study direct peripheral nerve repair: a systematic review.

Objective:Peripheral nerve repair is required after traumatic injury. This common condition represents a major public health problem worldwide. Recovery after nerve repair depends on several factors, including the severity of the injury, the nerve involved, and the surgeon’s technical skills. Despite the precise microsurgical repair of nerve lesions, adequate functional recovery is not always achieved and, therefore, the regeneration process and surgical techniques are still being studied. Pre-clinical animal models are essential for this research and, for this reason, the focus of the present systematic review (according to the PRISMA statement) was to analyze the different animal models used in pre-clinical peripheral nerve repair studies.Data sources:Original articles, published in English from 2000 to 2018, were collected using the Web of Science, Scopus, and PubMed databases.Data selection:Only preclinical trials on direct nerve repair were included in this review. The articles were evaluated by the first two authors, in accordance with predefined data fields.Outcome measures:The primary outcomes included functional motor abilities, daily activity and regeneration rate. Secondary outcomes included coaptation technique and animal model.Results:This review yielded 267 articles, of which, after completion of the screening, 49 studies were analyzed. There were 1425 animals in those 49 studies, being rats, mice, guinea pigs, rabbits, cats and dogs the different pre-clinical models. The nerves used were classified into three groups: head and neck (11), forelimb (8) and hindlimb (30). The techniques used to perform the coaptation were: microsuture (46), glue (12), laser (8) and mechanical (2). The follow-up examinations were histology (43), electrophysiological analysis (24) and behavioral observation (22).Conclusion:The most widely used animal model in the study of peripheral nerve repair is the rat. Other animal models are also used but the cost-benefit of the rat model provides several strengths over the others. Suture techniques are currently the first option for nerve repair, but the use of glues, lasers and bioengineering materials is increasing. Hence, further research in this field is required to improve clinical practice.

Local FK506 delivery at the direct nerve repair site improves nerve regeneration.

The objective of this study is to assess the efficacy of local tacrolimus (FK506) delivery to improve outcomes in the setting of nerve transection injury. FK506 embedded poly(lactide-co-caprolactone) films capable of extended, localized release of FK506 were developed. FK506 rate of release testing and bioactivity assay was performed. Mouse sciatic nerve transection and direct repair model was used to evaluate the effect extended, local delivery of FK506 had on nerve regeneration outcomes. Linear release of FK506 was observed for 30 days and released FK506 matched control levels of neurite extension in the dorsal root ganglion assay. Groups treated with local FK506 had greater gastrocnemius muscle weight, foot electromyogram, and number of axons distal of the repair site than non-FK506 groups. Results of this study indicate that extended, localized delivery of FK506 to nerve injuries can improve nerve regeneration outcomes in a mouse sciatic nerve transection and repair.

Facial reanimation: an update on nerve transfers in facial paralysis.

The aim of this article is to review the recent literature on nerve transfers in facial paralysis. The discussion focuses on direct nerve repair and three types of nerve transfers, cross facial nerve graft, hypoglossal, and masseter nerve transfers. Masseteric nerve transfers have a high probability of creating significant movement, although tone is poor. The hypoglossal to facial nerve transfer is reliable in affording facial tone and has been updated to involve a transposition technique that offers good results with minimal morbidity. Combination nerve transfer techniques using multiple cranial nerves or cross-face nerves are increasingly described. Reinnervation of the facial nerve and neural regeneration in general are areas of intense research and novel surgical approaches continue to be explored. Although direct nerve repair is the most ideal, other nerve transfers can be performed with good results. More specifically, the masseteric nerve transfer can provide excellent movement and the hypoglossal transfer good tone. Combination transfers may afford the benefits of multiple nerves.

Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk.

Spinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle. Five cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented. All 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients. Restoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.