Total Brachial Plexus Avulsion Injury Research Articles

Restoration of intrinsic hand function by superficial radial nerve: an anatomical study

BackgroundThe contralateral seventh cervical (cC7) nerve root transfer represents a cornerstone technique in treating total brachial plexus avulsion injury. Traditional cC7 procedures employ the entire ulnar nerve as a graft, which inevitably compromises its restorative capacity.ObjectiveOur cadaveric study seeks to assess this innovative approach aimed at preserving the motor branch of the ulnar nerve (MBUN). This new method aims to enable future repair stages, using the superficial radial nerve (SRN) as a bridge connecting cC7 and MBUN.MethodsWe undertook a comprehensive dissection of ten adult cadavers, generously provided by the Department of Anatomy, Histology, and Embryology at Fudan University, China. It allowed us to evaluate the feasibility of our proposed technique. For this study, we harvested only the dorsal and superficial branches of the ulnar nerve, as well as the SRN, to establish connections between the cC7 nerve and recipient nerves (both the median nerve and MBUN). We meticulously dissected the SRN and the motor and sensory branches of the ulnar nerve. Measurements were made from the reverse point of the SRN to the wrist flexion crease and the coaptation point of the SRN and MBUN. Additionally, we traced the MBUN from distal to proximal ends, recording its maximum length. We also measured the diameters of the nerve branches and tallied the number of axons.ResultsOur modified approach proved technically viable in all examined limbs. The distances from the reverse point of the SRN to the wrist flexion crease were 8.24 ± 1.80 cm and to the coaptation point were 6.60 ± 1.75 cm. The maximum length of the MBUN was 7.62 ± 1.03 cm. The average axon diameters in the MBUN and the anterior and posterior branches of the SRN were 1.88 ± 0.42 mm、1.56 ± 0.38 mm、2.02 ± 0.41 mm,respectively. The corresponding mean numbers of axons were 1426.60 ± 331.39 and 721.50 ± 138.22, and 741.90 ± 171.34, respectively.ConclusionThe SRN demonstrated the potential to be transferred to the MBUN without necessitating a nerve graft. A potential advantage of this modification is preserving the MBUN’s recovery potential.

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).

Proteomic analysis of trans-hemispheric motor cortex reorganization following contralateral C7 nerve transfer.

Nerve transfer is the most common treatment for total brachial plexus avulsion injury. After nerve transfer, the movement of the injured limb may be activated by certain movements of the healthy limb at the early stage of recovery, i.e., trans-hemispheric reorganization. Previous studies have focused on functional magnetic resonance imaging and changes in brain-derived neurotrophic factor and growth associated protein 43, but there have been no proteomics studies. In this study, we designed a rat model of total brachial plexus avulsion injury involving contralateral C7 nerve transfer. Isobaric tags for relative and absolute quantitation and western blot assay were then used to screen differentially expressed proteins in bilateral motor cortices. We found that most differentially expressed proteins in both cortices of upper limb were associated with nervous system development and function (including neuron differentiation and development, axonogenesis, and guidance), microtubule and cytoskeleton organization, synapse plasticity, and transmission of nerve impulses. Two key differentially expressed proteins, neurofilament light (NFL) and Thy-1, were identified. In contralateral cortex, the NFL level was upregulated 2 weeks after transfer and downregulated at 1 and 5 months. The Thy-1 level was upregulated from 1 to 5 months. In the affected cortex, the NFL level increased gradually from 1 to 5 months. Western blot results of key differentially expressed proteins were consistent with the proteomic findings. These results indicate that NFL and Thy-1 play an important role in trans-hemispheric organization following total brachial plexus root avulsion and contralateral C7 nerve transfer.

Structural and Functional Substitution of Deleted Primary Sensory Neurons by New Growth from Intrinsic Spinal Cord Nerve Cells: An Alternative Concept in Reconstruction of Spinal Cord Circuits.

In a recent clinical report, return of the tendon stretch reflex was demonstrated after spinal cord surgery in a case of total traumatic brachial plexus avulsion injury. Peripheral nerve grafts had been implanted into the spinal cord to reconnect to the peripheral nerves for motor and sensory function. The dorsal root ganglia (DRG) containing the primary sensory nerve cells had been surgically removed in order for secondary or spinal cord sensory neurons to extend into the periphery and replace the deleted DRG neurons. The present experimental study uses a rat injury model first to corroborate the clinical finding of a re-established spinal reflex arch, and second, to elucidate some of the potential mechanisms underlying these findings by means of morphological, immunohistochemical, and electrophysiological assessments. Our findings indicate that, after spinal cord surgery, the central nervous system sensory system could replace the traumatically detached original peripheral sensory connections through new neurite growth from dendrites.

Contralateral C7 Transfer via Both Vascularized Ulnar Nerve and Medial Antebrachial Cutaneous Nerve With the Ulnar Artery Anastomosed to the Arteria transversa Colli to Repair Brachial Plexus Avulsion

Background: Contralateral C7 nerve transfer to the median nerve has been used in an attempt to restore finger flexion in patients with total brachial plexus avulsion injury. However, the results have not been satisfactory mainly because of the requirement to use a long bridging nerve graft, which causes an extended nerve regeneration process and irreversible muscle atrophy. A new procedure involving contralateral C7 nerve transfer via both vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery anastomosed to the arteria transversa colli is presented here. Methods: It was performed in 25 patients with total brachial plexus avulsion injury. Contralateral C7 nerve root was coapted to the distal end of the ipsilateral vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery is anastomosed to the arteria transversa colli. The ulnar nerve was secured to the median nerve, and medial antebrachial cutaneous nerve was used to repair musculocutaneous nerve. Electromyography and ultrasonography were used to evaluate the early recovery. Recovery of finger, wrist, and elbow flexion was evaluated with the use of the modified British Medical Research Council muscle grading system. Results: Electromyography showed the early recovery by 3 months postoperatively, and smooth blood flow at the anastomotic stoma can be seen through ultrasound. The mean follow-up period (and standard deviation) was 20 ± 6 months. Motor function with a grade of M3+ or greater was attained in 60% of the patients for elbow flexion, 64% of the patients for finger flexion, 53% of the patients for thumb flexion, and 72% of the patients for wrist flexion. Conclusions: Contralateral C7 nerve transfer via both vascularized ulnar nerve and medial antebrachial cutaneous nerve with the ulnar artery anastomosed to the arteria transversa colli speeds up the nerve regeneration in patients with total brachial plexus avulsion injury and improve the utilization of contralateral C7 fiber. There was satisfactory recovery of finger flexion and wrist flexion in this series.

The Surgical Strategy for the Treatment of Total Brachial Plexus Avulsion Injury Patient

Objective: The total brachial plexus avulsion injury (BPAI) patients were treated in many organizations in the world, but the results reported differ significantly regarding different surgical strategy. Thus, this study aimed to evaluate the outcomes of different methods of nerve transfer and to determine a relatively optimal surgical strategy for treatment of total BPAI patients. Methods: A retrospective review was conducted on 73 patients with total BPAI who were treated with nerve transfer. The elbow flexion was reconstructed in 73 patients with phrenic nerve (PN) or intercostal nerves (ICNs) or contralateral C7 (cC7) transfer. The shoulder abduction was reconstructed in 73 patients with spinal accessory nerve (SAN) or ICNs transfer or both. Elbow extension was reconstructed in 35 patients with ICNs or cC7 transfer. Wrist and finger flexion were reconstructed in 73 patients with cC7 transfer. Wrist and finger extension were reconstructed in 31 patients with ICNs transfer. The mean follow-up period was 7.3 years. Results: The effective recovery rate were 79.5% in elbow flexion, 76.7% in shoulder abduction, 45.7% in elbow extension, 54.8% in wrist and finger flexion, 57.5% in median nerve area sensation, and 38.7% in wrist and finger extension. No significant difference was found in elbow flexion recovery between the patients with PN, ICN, or cC7 transfer. Shoulder abduction was significantly better in patients with SAN combined with ICNs transfer while no significant difference was found between the patients with anterior or posterior approach SAN transfer. Elbow extension was significantly better in patients with ICNs transfer. Entire cC7 transfer achieved significantly better recovery in wrist and finger flexion than partial cC7 transfer. Conclusion: For the treatment of total BPAI patients, we recommend PN transfer for elbow flexion, SAN combined with ICNs transfer for shoulder abduction, ICNs transfer for elbow extension, entire cC7 transfer for wrist and finger flexion, and ICNs transfer for finger extension, whereas for the elder or PN-injured patients, we recommend SAN combined with ICNs transfer for shoulder abduction, entire cC7 transfer for elbow flexion and wrist and finger flexion, and ICNs transfer for elbow extension and wrist and finger extension.

Differences in Brain Adaptive Functional Reorganization in Right and Left Total Brachial Plexus Injury Patients

Total brachial plexus avulsion injury (BPAI) results in the total functional loss of the affected limb and induces extensive brain functional reorganization. However, because the dominant hand is responsible for more cognitive-related tasks, injuries on this side induce more adaptive changes in brain function. In this article, we explored the differences in brain functional reorganization after injuries in unilateral BPAI patients. We applied resting-state functional magnetic resonance imaging scanning to 10 left and 10 right BPAI patients and 20 healthy control subjects. The amplitude of low-frequency fluctuation (ALFF), which is a resting-state index, was calculated for all patients as an indication of the functional activity level of the brain. Two-sample t-tests were performed between left BPAI patients and controls, right BPAI patients and controls, and between left and right BPAI patients. Two-sample t-tests of the ALFF values revealed that right BPAIs induced larger scale brain reorganization than did left BPAIs. Both left and right BPAIs elicited a decreased ALFF value in the right precuneus (P < 0.05, Alphasim corrected). In addition, right BPAI patients exhibited increased ALFF values in a greater number of brain regions than left BPAI patients, including the inferior temporal gyrus, lingual gyrus, calcarine sulcus, and fusiform gyrus. Our results revealed that right BPAIs induced greater extents of brain functional reorganization than left BPAIs, which reflected the relatively more extensive adaptive process that followed injuries of the dominant hand.

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

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

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

Contralateral C7 nerve transfer to the median nerve has been used in an attempt to restore finger flexion in patients with total brachial plexus avulsion injury. However, the results have not been satisfactory mainly because of the requirement to use a long bridging nerve graft, which causes an extended nerve regeneration process and irreversible muscle atrophy. A new procedure involving contralateral C7 nerve transfer via a modified prespinal route and direct coaptation with the injured lower trunk is presented here. Contralateral C7 nerve transfer via the modified prespinal route and direct coaptation with the injured lower trunk was performed in seventy-five patients with total brachial plexus avulsion injury. Thirty-five required humeral shortening osteotomy (3 to 4.5 cm) in order to accomplish the direct coaptation. The contralateral C7 nerve was also transferred to the musculocutaneous nerve through the bridging medial antebrachial cutaneous nerve arising from the lower trunk in forty-seven of the seventy-five patients. Recovery of finger, wrist, and elbow flexion was evaluated with use of the modified British Medical Research Council muscle grading system. The mean follow-up period (and standard deviation) was 57 ± 6 months (range, forty-eight to seventy-eight months). Motor function with a grade of M3+ or greater was attained in 60% of the patients for elbow flexion, 64% of the patients for finger flexion, 53% of the patients for thumb flexion, and 72% of the patients for wrist flexion. Contralateral C7 nerve transfer via a modified prespinal route and direct coaptation with the injured lower trunk decreases the distance for nerve regeneration in patients with total brachial plexus avulsion injury. There was satisfactory recovery of finger flexion and wrist flexion in this series. In addition, contralateral C7 nerve transfer was successfully used to repair two different target nerves: the lower trunk and the musculocutaneous nerve.

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

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

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

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

Long-term outcome of selective contralateral C7 nerve transfer

Objective To evaluate the long term outcome of patients treated with selective contralateral C7 transfer and to determine the factors affecting the outcomes of treatment. Methods Forty-six patients with total brachial plexus avulsion injuries were involved in this serial. All of the surgeries were performed by two stages and median nerve was the recipient nerve. Tne contralateral C7 nerve was used in three different ways. The whole root was used in eight patients; the major part except the anterior and medial part of the anterior division was used in 14 patients; the anterior or the posterior division was used in 24 patients. The functions of all the patients were evaluated by the British Medical Research Council (MRC) scale. Results The entire effective rate was 47.83% (22/46) in motor function and 56.52% (26/46) in sensory function. The more nerve fibers of C7 were used the better motor function were obtained. A better result of motor recovery could be induced if the interval between two stages was within four to eight months. And there seemed no statistically significant( P >0.05) in either motor or sensory function recovery with the difference of post trauma time. Conclusion Selective contralateral C7 transfer is an effective procedure in treating total brachial plexus avulsion injury. The more nerve fibers of C7 are used the better function recovery can be obtained and the ideal interval between two stages is four to eight months. The posttrauma time should be another key factor, and the surgery ought to be performed as early as possible. Key words: Brachial plexus; Median nerve; Follow-up studies; Contralateral C7; Selective repair

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

In this report, we present the findings of reinnervation of the thenar muscle in five patients who underwent the contralateral C7 nerve root transfers for repair of total brachial plexus root avulsions. Five (2 children and 3 adults) of 32 patients who received two-staged procedures of the contralateral C7 nerve root transfers to the median nerves showed reinnervation of thenar muscle were evaluated. The patients also received other procedures including the intercostal nerve transfer to the musculocutaneous nerve, the spinal accessory nerve to the suprascapular nerve, and the ipsilateral phrenic nerve to the musculocutaneous nerve before the contralateral C7 nerve root transfers. The patients were followed up from 24 to 118 months after surgery. Varied degrees of functional restorations were achieved after different procedures. The strength of abductor pollicis brevis (APB) muscle with Grade M2 was found in four patients. The incomplete interference pattern in the APB muscle was detected by electromyogram (EMG) in two patients, and the minority motor unit potential (MUP) was detected in other two patients. The strength of APB muscle was found with Grade M1 in one patient with EMG showing MUP. The findings from our series show reinnervation of thenar muscles after repair of the median nerve with the contralateral C7 nerve root transfer, which provides evidence for further investigation of reconstruction of the brachial plexus root avulsion injury with this procedure.

Spinal cord surgery after root avulsion injury in man results in motor and sensory recovery

Event Abstract Back to Event Spinal cord surgery after root avulsion injury in man results in motor and sensory recovery Thomas Carlstedt1* 1 Karolinska Institutet, Hand surgery, Sweden Spinal nerve root avulsion is a longitudinal spinal cord injury that affects mainly the final common motor pathway and the primary sensory medullary trajectories. In humans this occurs most frequently in traction injuries to the brachial plexus but also in trauma to the lumbosacral plexus and cauda equina as well as conus medullaris. This injury has serious effects on the pertinent spinal cord segment with the breakdown of connections and networks, death of motor, autonomic and sensory neurons and the development of a spinal cord scar. This injury often occurs as a result of road traffic accidents or violent acts. About 1000 patients are affected annually in the UK. The functional consequence of such injury is lower motoneuron syndromes, associated with autonomic paralysis including dysfunctional internal organs, limb muscle atrophy, sensory impairment and chronic pain. Spinal nerve root injury has been associated with an overall poor clinical outcome as a successful surgical repair would require axonal regrowth within the central nervous system as spinal cord regeneration. A surgical technique for the repair of this spinal cord injury was developed from basic science experiments and successfully translated to humans. Today, the reimplantation of avulsed ventral roots to the spinal cord in total brachial plexus avulsion injury restores useful proximal limb function and is the method of choice in the treatment of such devastating injuries. Even hand function can be restored by this technique. By means of functional magnetic resonance imaging (fMRI) it was established that the restored hand function relayed on pre-injury established cortical sensory program. Sensory roots are not possible to replant with functional recovery. Sensory recovery is therefore not occurring. In some cases as an expression of plasticity there are phenomenona observed as referrals of sensation to the denervated limb as well as hypersensitivity at border zones between normal and denervated dermatomes. When nerve graft has been implanted into the dorsal part of the spinal cord it has been possible to record return of some aspects of sensation. There was in such a case possible to elicit a biceps reflex and also record by means of electrophysiology a H-reflex proving that by this surgical technique it has been possible to restore a sensory-motor spinal cord reflex. However, neither quantitative sensory testing (QST), nor contact heat evoked potential stimulation (CHEPs) could demonstrate any exteroceptive sensory qualities. Pain, which is most severe and excruciating in most cases of brachial plexus avulsion injuries were found to be alleviated in conjunction with motor recovery after motor (but not sensory) root replantation. The mechanisms behind this are elusive but recent observations have indicated that there is retrograde transneuronal degeneration into the spinal cord dorsal horn following ventral root avulsion. This is reversed by ventral root replantation. These observation achieved by spinal cord surgery will serve as baseline data when assessing the effects of future application of adjuvant therapies Keywords: avulsion, Pain, Regeneration, Spinal Cord, spinal nerve root Conference: Karolinska Institutet 200 years anniversary Symposium on Traumatic Injuries in the Nervous System, Stockholm, Sweden, 15 Sep - 16 Sep, 2010. Presentation Type: Presentation Topic: Traumatic Injuries in the Nervous System Citation: Carlstedt T (2010). Spinal cord surgery after root avulsion injury in man results in motor and sensory recovery. Front. Neurol. Conference Abstract: Karolinska Institutet 200 years anniversary Symposium on Traumatic Injuries in the Nervous System. doi: 10.3389/conf.fneur.2010.56.00020 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 03 Sep 2010; Published Online: 21 Sep 2010. * Correspondence: Prof. Thomas Carlstedt, Karolinska Institutet, Hand surgery, Stockholm, Sweden, carlstedt.thomas@googlemail.com Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Thomas Carlstedt Google Thomas Carlstedt Google Scholar Thomas Carlstedt PubMed Thomas Carlstedt Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. 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