Fascicular Transfer Research Articles

Preoperative Donor Nerve Electromyography as a Predictor of Nerve Transfer Outcomes

We hypothesized that health of the donor nerve and corresponding muscle, as assessed by electromyography (EMG), could predict the outcome of nerve transfer surgery. A retrospective review was performed to investigate outcomes of nerve transfers for elbow flexion and shoulder abduction. Motor strength was graded preoperatively and after a minimum 1-year follow-up. Preoperative EMG results were classified as functionally normal or affected based on motor unit recruitment pattern and correlated with follow-up motor strength and range of motion. Forty nerve transfers were identified: 27 were performed for elbow flexion and 13 for shoulder abduction. Overall, the 29 transfers in the normal EMG cohort showed significantly greater postoperative improvement in motor strength (Medical Research Council grade 0.2-4.1) than the 11 transfers in the affected EMG cohort (grade 0.0-3.0). In the shoulder cohort, normal donor nerves resulted in greater strength (grade 4.0 vs. 2.4) and active motion (83° vs. 25°) compared with affected donor nerves. Double fascicular transfers with 2 normal donor nerves demonstrated improved strength compared with double nerve transfers when 1 donor nerve was affected (grade 4.5 vs. 3.2). Our findings demonstrate that a simple EMG classification that describes the quality of donor nerves can predict outcome as measured by postoperative motor strength and range of motion. Preoperative EMG evaluation should be considered a valuable supplementary component of the donor nerve selection process when planning brachial plexus reconstruction. Prognostic II.

A Prospective Study Comparing Single and Double Fascicular Transfer to Restore Elbow Flexion After Brachial Plexus Injury

The recovery of elbow flexion in upper brachial plexus injury can be achieved by the reinnervation of the biceps muscle (single reinnervation), but concomitant restoration of brachialis and biceps function (double reinnervation) has been recommended to improve elbow flexion strength. To prospectively compare morbidity and outcomes of single or double muscle reinnervation in restoring elbow flexion following incomplete injury to the brachial plexus. Forty consecutive patients were prospectively submitted to single or double muscle reinnervation. Elbow flexion strength was evaluated with a push-and-pull dynamometer 12 months after surgery. Hand morbidity related to the procedures was evaluated by the Semmes-Weinstein monofilaments test, quantification of static 2-point discrimination, and measurements of handgrip and lateral pinch strength in serial evaluations up to the final follow-up. Similar results for the strength of elbow flexion were observed in both groups. A worsening of sensibility, measured by using Semmes-Weinstein monofilaments, was identified in 8 patients, all of whom showed recovery during follow-up. No worsening of 2-point discrimination was observed. A decrease in handgrip and lateral pinch strength was identified in 8 and 9 patients, respectively, which improved during follow-up. There was no difference between the groups in the incidence of hand motor morbidity parameters. The strength of elbow flexion did not differ significantly between the groups treated with single or double muscle reinnervation. Deterioration of handgrip, lateral pinch strength, and sensibility measured by using Semmes-Weinstein monofilaments, was temporary, resulting in low morbidity for both techniques.

Double fascicular nerve transfer to the biceps and brachialis muscles after brachial plexus injury: clinical outcomes in a series of 29 cases

The clinical outcomes of patients with brachial plexus injuries who underwent double fascicular transfer (DFT) using fascicles from the median and ulnar nerves to reinnervate the biceps and brachialis muscles were evaluated. The authors conducted a retrospective chart review of 29 patients with brachial plexus injuries that were treated with DFT for restoration of elbow flexion. All patients underwent pre- and postoperative clinical evaluation using the Medical Research Council grading system. The mean patient age was 37 years (range 17-68 years), and there was a mean follow-up of 19 ± 12 months (range 8-68 months). At the most recent follow-up, all but 1 patient (97%) had regained elbow flexion. Eight patients recovered Grade M5, 15 patients recovered Grade M4, and 4 patients recovered Grade M3 elbow flexion strength. There was no evidence of functional deficit in the donor nerve distributions. Study results demonstrated the reliable restoration of M4-M5 elbow flexion following double fascicular transfer in patients with brachial plexus injuries.

Functional Recovery following an End to Side Neurorrhaphy of the Accessory Nerve to the Suprascapular Nerve: Case Report

The use of end-to-side neurrorhaphy remains a controversial topic in peripheral nerve surgery. The authors report the long-term functional outcome following a modified end-to-side motor reinnervation using the spinal accessory to innervate the suprascapular nerve following a C5 to C6 avulsion injury. Additionally, functional outcomes of an end-to-end neurotization of the triceps branch to the axillary nerve and double fascicular transfer of the ulnar and medial nerve to the biceps and brachialis are presented. Excellent functional recoveries are found in respect to shoulder abduction and flexion and elbow flexion. The online version of this article (doi:10.1007/s11552-009-9242-3) contains supplementary material, which is available to authorized users.

Concepts of nerve regeneration and repair applied to brachial plexus reconstruction

Brachial plexus injury is a serious condition that usually affects young adults. Progress in brachial plexus repair is intimately related to peripheral nerve surgery, and depends on clinical and experimental studies. We review the rat brachial plexus as an experimental model, together with its behavioral evaluation. Techniques to repair nerves, such as neurolysis, nerve coaptation, nerve grafting, nerve transfer, fascicular transfer, direct muscle neurotization, and end-to-side neurorraphy, are discussed in light of the authors' experimental studies. Intradural repair of the brachial plexus by graft implants into the spinal cord and motor rootlet transfer offer new possibilities in brachial plexus reconstruction. The clinical experience of intradural repair is presented. Surgical planning in root rupture or avulsion is proposed. In total avulsion, the authors are in favor of the reconstruction of thoraco-brachial and abdomino-antebrachial grasping, and on the transfer of the brachialis muscle to the wrist extensors if it is reinnervated. Surgical treatment of painful conditions and new drugs are also discussed.

Results of Reinnervation of the Biceps and Brachialis Muscles with a Double Fascicular Transfer for Elbow Flexion

To report the results of a surgical technique of nerve transfer to reinnervate the brachialis muscle and the biceps muscle to restore elbow flexion after brachial plexus injury. Retrospective review was performed on 6 patients who had direct nerve transfer of a single expendable motor fascicle from both the ulnar and median nerves directly to the biceps and brachialis branches of the musculocutaneous nerve. Assessment included degree of recovery of elbow flexion and ulnar and median nerve function including pinch and grip strengths. Clinical evidence of reinnervation was noted at a mean of 5.5 months (SD, 1 mo; range, 3.5-7 mo) after surgery and the mean follow-up period was 20.5 months (SD, 11.2 mo, range, 13-43 mo). Mean recovery of elbow flexion was Medical Research Council grade 4+. Postoperative pinch and grip strengths were unchanged or better in all patients. No motor or sensory deficits related to the ulnar or median nerves were noted and all patients maintained good hand function. No patients required additional procedures to further improve elbow flexion strength. Transfer of expendable motor fascicles from the ulnar and median nerves successfully can reinnervate the biceps and brachialis muscles for strong elbow flexion. The reinnervation of the brachialis muscle, the primary elbow flexor, as well as the biceps muscle provides an additional biomechanical advantage that accounts for the excellent elbow flexion strength obtained using this technique. Direct coaptation of the nerve fascicles was performed without the need for nerve grafts and there was no functional or sensory donor morbidity.

Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction

The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion. Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90 degrees and 92 degrees in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70 degrees. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3 + and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites. Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.

Nerve repair by end-to-side coaptation or fascicular transfer: a clinical study.

End-to-side nerve repair has recently achieved special interest in the laboratory. In clinical practice, its use remains controversial and very few studies have been published. In the present report, nerve repair by end-to-side neurorrhaphy and by fascicular transfer is evaluated in seven patients. Clinical, electrophysiologic and histologic recovery was not observed in the patients who underwent end-to-side nerve coaptation, but recovery was observed when a fascicular transfer was performed.