Nerve Transfer For Elbow Flexion Research Articles

Effect of shorter nerve graft and selective motor branch of recipient nerve on nerve transfer surgery for elbow flexion in patients with brachial plexus injury.

The spinal accessory nerve (SAN) is commonly used as a donor nerve for reinnervation of elbow flexors in brachial plexus injury (BPI) reconstruction. However, no study has compared the postoperative outcomes between SAN-to-musculocutaneous nerve (MCN) transfer and SAN-to-nerve to biceps (NTB) transfer. Thus, this study aimed to compare the postoperative time to recovery of elbow flexors between the two groups. A total of 748 patients who underwent surgical treatment for BPI between 1999 and 2017 were retrospectively reviewed. Among them, 233 patients were treated with nerve transfer for elbow flexion. Two techniques were used to harvest the recipient nerve: the standard dissection technique and the proximal dissection technique. The postoperative motor power of elbow flexion was assessed every month for 24 months using the Medical Research Council (MRC) grading system. Survival and Cox regression analyses were used to compare the time to recovery (MRC grade ≥ 3) between the two groups. Of the 233 patients who underwent nerve transfer surgery, there were 162 patients in the MCN group and 71 patients in the NTB group. At 24 months after surgery, the MCN group had a success rate of 74.1%, and the NTB group had a success rate of 81.7% (p = 0.208). When compared with the MCN group, the NTB group had a significantly shorter median time to recovery (19 months vs 21 months, p = 0.013). Only 11.1% of patients in the MCN group regained MRC grade 4 or 5 motor power 24 months after nerve transfer surgery compared with 39.4% patients in the NTB group (p < 0.001). Cox regression analysis showed that the SAN-to-NTB transfer in combination with the proximal dissection technique was the only significant factor affecting time to recovery (HR 2.33, 95% CI 1.46-3.72; p < 0.001). SAN-to-NTB transfer in combination with the proximal dissection technique is the preferred nerve transfer option for restoration of elbow flexion in traumatic pan-plexus palsy.

Nerve Transfers for Elbow Reconstruction in Upper and Extended Upper-Type Brachial Plexus Injuries: A Case Series.

Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries. To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries. A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P &lt; .05. Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance. Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.

Self-assessed outcomes following double fascicular nerve transfer for elbow flexion.

Double fascicular nerve transfer (DFT) is often performed to re-animate the elbow flexors. Studies of motor recovery following this surgery have exclusively reported on the objective outcome of muscle power. Questionnaire studies allow researchers and clinicians to learn from patients and better direct care towards their needs. To date, no research has focused on self-assessed recovery following DFT for elbow flexion. This observational cross-sectional study aimed to give an account of patient-assessed outcomes following DFT. The bespoke questionnaire included: (a) self-reported strength and (b) the Stanmore percentage of normal elbow assessment. Sixty-two patients participated in the study. Participants were grouped according to time post-surgery. Statistical analysis confirmed that data were comparable between groups (p=0.10). Median scores were 0.5 kg <2 years post-surgery, 3 kg at 2 to 5 years, 2 kg at 5 to 8 years and 1.3 kg in the >8 years group. Mean scores (%) were 35 (SD ± 25) <2 years, 56 (SD ± 31) at 2 to 5 years, 44 (SD ± 25) at 5 to 8 years and 46 (SD ± 29) >8 years groups. This is the first study of self-assessed recovery following DFT. Scores peaked around 4 years post-operation. Future research should focus on the long-term self-reported outcome of nerve transfer surgery.

The association between number of intercostal nerves transferred and elbow flexion: a systematic review and pooled analysis

Objective This pooled analysis evaluates the association between the number of nerves transferred and postoperative outcomes after intercostal nerve (ICN) nerve transfer for elbow flexion. Methods A systematic and pooled analysis of studies reporting individual patient demographics and outcomes after ICN-musculocutaneous nerve (MCN) transfer for traumatic brachial plexus injury was conducted. The primary outcome was the ability to attain an elbow flexion Medical Research Council (MRC) score of ≥4 at the final postoperative follow-up visit. Results Ten studies were included for a total of 128 patients. There were 43 patients who underwent two ICNT, 77 patients who underwent three ICNT, and 8 patients who underwent four ICNT. The three groups did not differ in ability to achieve MRC ≥ 4 (2ICNT 48.8%, 3ICNT 42.9%, 4ICNT 50.0%, p = 0.789). The number of ICNs transferred was not associated with MRC scores ≥4 on the multivariable analysis (OR: 0.55, p = 0.126). Conclusions These results indicate that two ICN transfers may be as effective as three ICN and four ICN transfers and highlight the potential for nonsurgical factors to influence postoperative outcomes. Taken together, this pooled analysis leads us to question the utility of transferring >2 ICNs for MCN neurotization.

Restoration of elbow flexion in adult traumatic brachial plexus injury – a quantitative analysis of results of single versus double nerve transfer

BackgroundRestoration of elbow flexion is one of the key components of adult brachial plexus surgery. Nerve transfers are routinely used to attain elbow flexion. PurposeThis study aims to quantify the recovery of elbow flexion power and to compare the outcome following single nerve transfer and double nerve transfer to branches of the musculocutaneous nerve in adult traumatic brachial plexus injury. MethodWe conducted a retrospective cohort study of patients with traumatic upper brachial plexus injury who underwent nerve transfer of the musculocutaneous nerve with either Ulnar nerve fascicles (SN) or both Ulnar and Median nerve fascicles (DN) for restoring elbow flexion. Patients with a minimum follow up of 18 months after surgery were included in this study. Elbow flexion strength was quantified using a force transducer and software module and the results were compared between the two groups. ResultThe median strength of elbow flexion was 14.3 Newton meter. In the SN group, the mean strength of elbow flexion was 5.4 ± 5 Nm, and for DN group it was 20.4 ± 9.9 Nm. Elbow flexion strength following DN procedure was significantly better when compared with SN. ConclusionThe additional nerve transfer of median nerve fascicles with musculocutaneous nerve branch to the brachialis muscle does not add clinically obvious morbidity to the patient but has definite benefit as observed in this study. We advocate double fascicular nerve transfer for elbow flexion in upper brachial plexus injuries if the median and ulnar nerve functions are normal.

Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series.

The phrenic nerve has been extensively reported to be a very powerful source of transferable axons in brachial plexus injuries. The most used technique used is supraclavicular sectioning of this nerve. More recently, video-assisted thoracoscopic techniques have been reported as a good alternative, since harvesting a longer phrenic nerve avoids the need of an interposed graft. To compare grafting vs phrenic nerve transfer via thoracoscopy with respect to mean elbow strength at final follow-up. A retrospective analysis was conducted among patients who underwent phrenic nerve transfer for elbow flexion at 2 centers from 2008 to 2017. All data analysis was performed in order to determine statistical significance among the analyzed variables. A total of 32 patients underwent supraclavicular phrenic nerve transfer, while 28 underwent phrenic nerve transfer via video-assisted thoracoscopy. Demographic characteristics were similar in both groups. A statistically significant difference in elbow flexion strength recovery was observed, favoring the supraclavicular phrenic nerve section group against the intrathoracic group (P=.036). A moderate though nonsignificant difference was observed favoring the same group in mean elbow flexion strength. Also, statistical differences included patient age (P=.01) and earlier time from trauma to surgery (P=.069). Comparing supraclavicular sectioning of the nerve vs video-assisted, intrathoracic nerve sectioning to restore elbow flexion showed that the former yielded statistically better results than the latter, in terms of the percentage of patients who achieve at least level 3 MRC strength at final follow-up. Furthermore, larger scale prospective studies assessing the long-term effects of phrenic nerve transfers remain necessary.

Comparative study of phrenic and partial ulnar nerve transfers for elbow flexion after upper brachial plexus avulsion: A retrospective clinical analysis

The widely used nerve transfer sources for elbow flexion in patients with upper brachial plexus avulsion (UBPA) include partial ulnar nerve, phrenic nerve, and intercostal nerves. A retrospective review of 21 patients treated with phrenic and partial ulnar nerve transfers for elbow flexion after UBPA was carried out. In the phrenic nerve transfer group, the phrenic nerve was transferred to the anterolateral bundle of the anterior division of the upper trunk; in the partial ulnar nerve transfer group, one fascicle of the ulnar nerve was transferred to the biceps branch. The British Medical Research Council (MRC) grading system, angle of elbow flexion, electromyography (EMG), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scoring were used to evaluate the recovery of elbow flexion at least 3 years postoperatively. The efficiency of motor function in phrenic nerve transfer group was 82%, whereas it was 80% in partial ulnar nerve transfer group. The outstanding rates of angle of elbow flexion were 64% and 70% in phrenic and partial ulnar nerve transfer groups, respectively. The DASH scores after surgery were significantly lower than those before surgery in the two groups. There was no statistical difference between the two groups in the changes of DASH scores before and after surgery. Both of phrenic and partial ulnar nerve transfers had good prognosis for elbow flexion in patients with UBPA.

Timing of nerve transfer for elbow flexion in neonatal brachial plexus palsy

BackgroundNeonatal brachial plexus palsy (NBPP) occurs in 1–4/1000 live births, and those with palsies of the upper trunk can suffer permanent loss of elbow flexion. One option for restoring elbow flexion comprises nerve transfer from an ulnar nerve fascicle to the musculocutaneous nerve branch to biceps, also known as the Oberlin procedure. Although outcomes are encouraging, the timing of surgical intervention from the time of injury continues to be controversial. MethodsWe performed a retrospective review of infants with NBPP who underwent Oberlin transfer procedure. Outcome measures included active range of motion and muscle power (MRC grade) at serial examinations up to 12 months. ResultsWe demonstrate a positive trend in outcomes of elbow flexion and supination in patients intervened on earlier rather than later. ConclusionsThe optimal timing in the use of Oberlin transfer in the NBPP population is not well defined. Our study is the first to focus on ulnar to musculocutaneous nerve transfer timing in NBPP, and we demonstrate a positive trend in functional outcomes with earlier surgery.

Evaluation of nerve transfer options for treating total brachial plexus avulsion injury: A retrospective study of 73 participants

Despite recent great progress in diagnosis and microsurgical repair, the prognosis in total brachial plexus-avulsion injury remains unfavorable. Insufficient number of donors and unreasonable use of donor nerves might be key factors. To identify an optimal treatment strategy for this condition, we conducted a retrospective review. Seventy-three patients with total brachial plexus avulsion injury were followed up for an average of 7.3 years. Our analysis demonstrated no significant difference in elbow-flexion recovery between phrenic nerve-transfer (25 cases), phrenic nerve-graft (19 cases), intercostal nerve (17 cases), or contralateral C7-transfer (12 cases) groups. Restoration of shoulder function was attempted through anterior accessory nerve (27 cases), posterior accessory nerve (10 cases), intercostal nerve (5 cases), or accessory + intercostal nerve transfer (31 cases). Accessory nerve + intercostal nerve transfer was the most effective method. A significantly greater amount of elbow extension was observed in patients with intercostal nerve transfer (25 cases) than in those with contralateral C7 transfer (10 cases). Recovery of median nerve function was noticeably better for those who received entire contralateral C7 transfer (33 cases) than for those who received partial contralateral C7 transfer (40 cases). Wrist and finger extension were reconstructed by intercostal nerve transfer (31 cases). Overall, the recommended surgical treatment for total brachial plexus-avulsion injury is phrenic nerve transfer for elbow flexion, accessory nerve + intercostal nerve transfer for shoulder function, intercostal nerves transfer for elbow extension, entire contralateral C7 transfer for median nerve function, and intercostal nerve transfer for finger extension. The trial was registered at ClinicalTrials.gov (identifier: NCT03166033).

Abstract: Enhancement of Voluntary Elbow Movement with a Myoelectric Orthotic Device: Long Term Follow Up of a Novel Application of a Post-Cva Assistive Rehabilitation Orthotic Device

INTRODUCTION: Free functioning muscle transfers (FFMTs), nerve grafting and nerve transfers have led to improved functional outcomes in brachial plexus injury (BPI) patients. Reports have shown that 39% of FFMTs and 26% of nerve transfers for elbow flexion achieve ≥ M4 elbow flexion strength.1 However, there remains a substantial number of patients with less favorable functional outcomes that need to be addressed further. The MyoPro (Myomo Inc., Cambridge, MA, USA) is a FDA-cleared myoelectric elbow-wrist-hand orthosis that uses surface EMG signals from affected muscle groups to control a powered orthosis to assist with the movement of a paretic upper limb. We describe the application of this orthosis for enhancement of elbow flexion and extension in patients with incomplete recovery from BPI. METHODS: Two patients from a single-surgeon practice have been evaluated for suitability of the myoelectric functional orthotic device. Both patients are 37 year-old men with 14 and 17 years history of left and right BPIs. Patient-1 initially had BP reconstruction by nerve transfers and secondarily a FFMT for restoration of elbow flexion and finger extension. Patient-2 underwent brachial plexus exploration and neurolysis only. Both patients failed to regain voluntary elbow movement. Evaluation showed 0–130 degree elbow passive range of motion in flail arms. Both patients had detectable EMG signals in the biceps or gracilis, and triceps muscles. Patients underwent 30 minutes of training with the device, which provides powered assistance for elbow flexion and extension via motors attached to the exterior of the orthosis. After the training, patients were asked to perform voluntary assisted elbow flexion and extension. Patients were then referred to receive custom orthotic devices. Functional assessment was performed using disabilities of the arm, shoulder and hand (DASH) questionnaire. RESULTS: Both patients demonstrated voluntary active elbow flexion and extension from 0 to 115 degrees using EMG control signals from the gracilis and triceps in Patient-1, and from the biceps and triceps muscles in Patient-2. Patient-1 quitted before getting the custom device. Patient-2 had DASH scores of 44.17 before and 36.6 after 6 months of using the orthotic device. CONCLUSION: Given the limited options available after definitive reconstruction, this myoelectric orthosis is a valuable option to improve the functional outcome in patients with BPI and poor return of voluntary elbow movement following reconstruction. Reference Citations: 1. Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Free Functioning Gracilis Muscle Transfer versus Intercostal Nerve Transfer to Musculocutaneous Nerve for Restoration of Elbow Flexion after Traumatic Adult Brachial Pan-Plexus Injury. Plast Reconstr Surg. 2016 Sep;138(3):483e-8e.

Comparative Study of Phrenic and Intercostal Nerve Transfers for Elbow Flexion After Global Brachial Plexus Injury

Objective: The aim of this study was to compare phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury. Methods: A retrospective review of 33 patients treated with phrenic and intercostal nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. Phrenic nerve transfer group: phrenic nerve was transferred to anterolateral bundle of anterior division of upper trunk (23 patients); intercostal nerve transfer group: three intercostal nerves were coapted to the anterolateral bundles of musculocutaneous nerve. The British Medical Research Council (MRC) grading system, angle of elbow flexion, and electromyography (EMG) were used to evaluate the recovery of elbow flexion at least 3 years after surgery. Results: The efficiency of motor function in phrenic nerve transfer group was 83%, while it was 70% in intercostal nerve transfer group. The 2 groups were not statistically different in terms of MRC grade ( P = .646) and EMG results ( P = .646). The outstanding rates of angle of elbow flexion were 48% and 40% in phrenic and intercostal nerve transfer groups, respectively. There was no significant difference of outstanding rates in angle of elbow flexion between the 2 groups. Conclusion: Phrenic nerve transfer had a higher proportion of good prognosis for elbow flexion than intercostal nerve transfer, but the effective and outstanding rate had no significant difference for biceps reinnervation between the 2 groups according to MRC grading, angle of elbow flexion, and EMG.

How late is too late for nerve transfers

Traditionally, the degeneration of the motor endplates has placed a limit on the accepted delay for nerve reconstruction. Nerve transfers have helped to deliver growing axons very close to the target muscles so that the post-operative denervation is shortened. Despite efforts at spreading awareness of surgical indications, there are instances where the patient presents late to a specialized brachial plexus unit. In such cases, one faces the dilemma of using traditional nerve transfers or opting for a free functioning muscle transfer. Some surgeons rely on the presence of fibrillations on the EMG to help them decide about the feasibility of re-innervation. However, there are no clear guidelines. I would like to present a study of 50 patients operated at 9 months or later (9-19.5 months) from the accident. I have excluded cases operated later than April 2013, as the follow-up is too short. Their ages ranged from 4-57 years with a mean of 28.6 years (31 of the 50 patients belonged the range 10-30 years). There were 15 total palsies, 15 cases of C567 palsies, 9 cases of C56 palsies, one case of isolated C8T1 involvement and 10 infraclavicular palsies (injuries beyond the trunks). Among the nerve transfers for elbow flexion, intercostals were transferred to the musculocutaneous in 15 cases. Biceps of at least grade 3 strength was restored in 5/15 patients. Ulnar to biceps transfer was done in 22 cases (+median to brachialis in 16 of these). 17 of these patients regained elbow flexion stronger than grade 3. The spinal accessory nerve was transferred to the suprascapular nerve in 34 cases and grade 3 supraspinatus was achieved in 20 patients. However, the cases of successful restoration of shoulder abduction included 7 patients with C56 palsies and 4 of C567 palsies. Thus, from these observations it appears that: 1. In total palsies, the failure rate of intercostals to musculocutaneous and spinal accessory to suprascular nerve transfers is far higher than the overall average in my series. 2. The failure rate for ulnar to biceps transfer remains unchanged even up to 19.5 months from the accident. 3. Shoulder abduction is a reasonable expectation after a nerve transfer in a partial palsy even at delays longer than 10 months. I recommend that one should not succumb to the temptation to perform traditional nerve reconstruction in patients with flail upper limbs that present late, even if they are young. The available nerve transfers should be utilized for innervation of free functioning muscles. On the other hand, we can continue to have an optimistic outlook for C56 palsies even at delays as long as 18-19 months.

Comparative study of phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury

BackgroundGlobal brachial plexus injuries (BPIs) are devastating events frequently resulting in severe functional impairment. The widely used nerve transfer sources for elbow flexion in patients with global BPIs include intercostal and phrenic nerves. ObjectiveThe aim of this study was to compare phrenic and intercostal nerve transfers for elbow flexion after global BPI. MethodsA retrospective review of 33 patients treated with phrenic and intercostal nerve transfer for elbow flexion in posttraumatic global root avulsion BPI was carried out. In the phrenic nerve transfer group, the phrenic nerve was transferred to the anterolateral bundle of the anterior division of the upper trunk (23 patients); in the intercostal nerve transfer group, three intercostal nerves were coapted to the anterolateral bundles of the musculocutaneous nerve. The British Medical Research Council (MRC) grading system, angle of elbow flexion, and electromyography (EMG) were used to evaluate the recovery of elbow flexion at least 3 years postoperatively. ResultsThe efficiency of motor function in the phrenic nerve transfer group was 83%, while it was 70% in the intercostal nerve transfer group. The two groups were not statistically different in terms of the MRC grade (p=0.646) and EMG results (p=0.646). The outstanding rates of angle of elbow flexion were 48% and 40% in the phrenic and intercostal nerve transfer groups, respectively. There was no significant difference of outstanding rates in the angle of elbow flexion between the two groups. ConclusionPhrenic nerve transfer had a higher proportion of good prognosis for elbow flexion than intercostal nerve transfer, but the effective and outstanding rate had no significant difference for biceps reinnervation between the two groups according to MRC grading, angle of elbow flexion, and EMG.

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.

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.

Double nerve transfer for elbow flexion in obstetric brachial plexus injury: A case report

We report a case of a 10-month-old boy with a left extended upper type (C5-C7) obstetric brachial plexus injury that was treated with double nerve transfer (partial ulnar and partial median nerve transfer) to restore elbow flexion and spinal accessory nerve transfer to the suprascapular nerve to restore shoulder abduction. At 60 months' follow-up, shoulder abduction was 0-150° (M4) and elbow flexion was 0-140° (M5). Elbow, wrist and finger extension improved to M5. However, shoulder external rotation was only 0-30° (from full internal rotation). No weakness on finger and wrist flexion was observed. Double nerve transfers to restore elbow flexion can be safely done in obstetric brachial plexus injuries with good results. Secondary surgeries may be needed to improve external rotation.

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

REFERENCES 1. Ferraresi S, Garozzo D, Ravenni R, et al. Hemihypoglossal nerve transfer in brachial plexus repair: Technique and results. Neurosurgery 2002; 50: 332–5. 2. Zheng MX, Xu WD, Qiu YQ, et al. Phrenic Nerve transfer for elbow flexion and intercostal nerve transfer for elbow extension. J Hand Surg Am 2010; 35: 1304-9. 3. Monreal R. Restoration of elbow flexion by transfer of the phrenic nerve to musculocutaneous nerve after brachial plexus injuries. Hand 2007; 2: 206–11. 4. Siqueira MG, Martins RS. Phrenic nerve transfer in the restoration of elbow flexion in brachial plexus avulsion injuries: how effective and safe is it? Neurosurgery 2009; 65: A125-31. 5. Luedemann W, Hamm M, BLOMER U, et al. Brachial plexus neurotization with donor phrenic nerves and its effect on pulmonary function. J Neurosurg 2002; 96: 523–6. 6. Bowerson M, Nelson VS, Yang LJ. Diaphragmatic paralysis associated with neonatal brachial plexus palsy. Pediatr Neurol 2009; 42: 234-6. 7. Xu L, Gu Y, Xu J, et al. Contralateral C7 transfer via the prespinal and retropharyngeal route to repair brachial plexus root avulsion: a preliminary report. Neurosurgery 2008; 63: 553-9. 8. Lundborg G. Nerve injury and repair-a challenge to the plastic brain. J Peripher Nerv Syst 2003; 8: 209-26. 9. Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 2000; 106: 1097–124. 10. Xu WD, Gu YD, Xu JG, et al. Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury. Plast Reconstr Surg 2002; 110: 104–9.

Comparison of Single versus Double Nerve Transfers for Elbow Flexion after Brachial Plexus Injury

Restoration of elbow flexion is commonly achieved with nerve transfer to the musculocutaneous nerve branches after upper trunk brachial plexus injury. It is unknown if double nerve transfer to the biceps and brachialis nerve branches results in greater strength than single nerve transfer to the biceps branch alone. A retrospective review was performed of all patients receiving nerve transfer to restore elbow flexion. Single and double nerve transfers were compared in regard to severity of injury, elbow flexion, supination, grip strengths, and Disabilities of the Arm, Shoulder, and Hand scores. Elbow flexion and supination torque strength were measured quantitatively. Fifty-five patients underwent nerve transfer to restore elbow flexion (23 single, 32 double). At similar follow-up periods, British Medical Research Council grade improved to 4 or better in 14 of 21 single and 24 of 30 double nerve transfer patients. Supination strength was similar between groups (p = 0.148). Grip strength was greater in the double nerve transfer patients (p = 0.028). Preoperative Disabilities of the Arm, Shoulder, and Hand scores were significantly greater in single versus double nerve transfer patients (p = 0.018). Although single nerve transfer patients had a greater improvement in scores, the final mean scores were similar in the two groups. The severity of injury was different between the two groups, with 19 of 23 single nerve transfer patients having injury beyond the C5-6 level and only 16 of 32 of double nerve transfer patients with greater than C5-6 injury (p = 0.020). Outcomes are similar between the two groups for elbow flexion and supination strength. Postoperative Disabilities of the Arm, Shoulder, and Hand scores are similar in single and double nerve transfer patients.

Phrenic Nerve Transfer for Elbow Flexion and Intercostal Nerve Transfer for Elbow Extension

To explore long-term recovery of elbow flexion and extension after transferring the phrenic nerve and intercostal nerves, respectively, in adults with global brachial plexus avulsion injuries. Seven adults with global brachial plexus avulsion injuries had the phrenic nerve transferred to the musculocutaneous nerve (or to the anterior division of upper trunk) and intercostal nerves transferred to the triceps branch of the radial nerve at our hospital 7 to 12 years ago. The results of elbow motor strength testing using the Medical Research Council grading scale, and electrodiagnostic findings using electromyogram examinations, were studied retrospectively. Pulmonary function tests were also performed at final visits. Functional elbow flexion was obtained in most of the 7 cases (M2, 1; M3, 3; M4, 2; and M5, 1) but elbow extension was absent or insufficient in all subjects (M0, 1; M1, 3; and M2, 3). Electrical results showed successful biceps reinnervation in 6 patients and successful triceps reinnervation in 5. No patient experienced breathing problems, and pulmonary function results were within normal range. In the long term, after brachial plexus avulsion injury in most patients who underwent both phrenic nerve and intercostal nerve transfer to achieve elbow flexion and extension eventually obtained satisfactory elbow flexion but poor elbow extension. We recommend against transferring the intercostal nerves to the triceps branch of radial nerve in conjunction with primary phrenic to musculocutaneous nerve transfer. Therapeutic IV.

Comparison of Single and Double Nerve Transfer for Elbow Flexion after Brachial Plexus Injury: Level 3 Evidence

Comparison of Single and Double Nerve Transfer for Elbow Flexion after Brachial Plexus Injury: Level 3 Evidence