Skip to main content

Advertisement

SpringerLink
Log in

Phrenic nerve neurotization utilizing the spinal accessory nerve: technical note with potential application in patients with high cervical quadriplegia

  • Technical Note
  • Published:
Child's Nervous System Aims and scope Submit manuscript

Abstract

Introduction

High cervical quadriplegia is associated with high morbidity and mortality. Artificial respiration in these patients carries significant long-term risks such as infection, atelectasis, and respiratory failure. As phrenic nerve pacing has been proven to free many of these patients from ventilatory dependency, we hypothesized that neurotization of the phrenic nerve with the spinal accessory nerve (SAN) may offer one potential alternative to phrenic nerve stimulation via pacing and may be more efficacious and longer lasting without the complications of an implantable device.

Materials and methods

Ten cadavers (20 sides) underwent exposure of the cervical phrenic nerve and the SAN in the posterior cervical triangle. The SAN was split into anterior and posterior halves and the anterior half transposed to the ipsilateral phrenic nerve as it crossed the anterior scalene muscle.

Results

The mean distance between the cervical phrenic nerve and the SAN in the posterior cervical triangle was 2.5 cm proximally, 4 cm at a midpoint, and 6 cm distally. The range for these measurements was 2 to 4 cm, 3.5 to 5 cm, and 4 to 8.5 cm, respectively. The mean excess length of SAN available after transposition to the more anteromedially placed phrenic nerve was 5 cm (range 4 to 6.5 cm). The mean diameter of these regional parts of the spinal accessory and phrenic nerves was 2 and 2.5 mm, respectively. No statistically significant difference was found for measurements between sides.

Conclusions

To our knowledge, using the SAN for neurotization to the phrenic nerve for potential use in patients with spinal cord injury has not been previously explored. Following clinical trials, these data may provide a mechanism for self stimulation of the diaphragm and obviate phrenic nerve pacing in patients with high cervical quadriplegia. Our study found that such a maneuver is technically feasible in the cadaver.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Alnot JY, Oberlin C (1996) Nerves available for neurotization. In: Alnot JY, Narakas A (eds) Traumatic brachial plexus injuries. Expansion Scientifique Française, Paris, pp 33–38

    Google Scholar 

  2. Baer GA, Talonen PP, Häkkinen V, Exner G, Yrjölä H (1990) Phrenic nerve stimulation in tetraplegia. A new regimen to condition the diaphragm for full-time respiration. Scand J Rehabil Med 22:107–111

    PubMed  CAS  Google Scholar 

  3. Bonnard C, Narakas A (1996) Neurotization using the spinal accessory nerve in the brachial plexus lesions. In: Alnot JY, Narakas A (eds) Traumatic brachial plexus injuries. Expansion Scientifique Française, Paris, pp 156–166

    Google Scholar 

  4. Carlstedt T, Anand P, Htut M, Misra P, Svensson M (2004) Restoration of hand function and so called “breathing arm” after intraspinal repair of C5-T1 brachial plexus avulsion injury. Neurosurg Focus 16:1–5

    Article  Google Scholar 

  5. Dailiana ZH, Mehdian H, Gilbert A (2001) Surgical anatomy of spinal accessory nerve: is trapezius functional deficit inevitable after division of the nerve? J Hand Surg 26:137–141

    CAS  Google Scholar 

  6. DiMarco AF (2005) Restoration of respiratory muscle function following spinal cord injury. Review of electrical and magnetic stimulation techniques. Respir Physiol Neurobiol 147:273–287

    Article  PubMed  Google Scholar 

  7. Garrido H, Mazaira J, Gutierrez P, Gonzalez E, Rivas J, Madrazo J (1987) Continuous respiratory support in quadriplegic children by bilateral phrenic nerve stimulation. Thorax 42:573–577

    PubMed  CAS  Google Scholar 

  8. Glenn WWL, Hogan KF, Loke JSO, Ciesielski TE, Phelps ML, Rowedder R (1984) Ventilatory support by pacing of the conditioned diaphragm in quadriplegia. N Engl J Med 310:1150–1155

    PubMed  CAS  Google Scholar 

  9. Glenn WW, Gee JB, Schachter EN (1978) Diaphragm pacing. Application to a patient with chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 75:273–281

    PubMed  CAS  Google Scholar 

  10. Kierner AC, Zelenka I, Heler S, Burian M (2000) Surgical anatomy of the spinal accessory nerve and the trapezius branches of the cervical plexus. Arch Surg 135:1428–1431

    Article  PubMed  CAS  Google Scholar 

  11. Kim DH, Cho YJ, Tiel RL, Kline DG (2003) Surgical outcomes of 111 spinal accessory nerve injuries. Neurosurgery 53:1106–1113

    Article  PubMed  Google Scholar 

  12. Krieger AJ, Krieger AJ (2000) The intercostal to phrenic nerve transfer: an effective means of reanimating the diaphragm in patients with high cervical spine injury. Plast Reconstr Surg 105:1255–1261

    Article  PubMed  CAS  Google Scholar 

  13. Krieger AJ, Danetz I, Wu SZ, Spatola M, Sapru HN (1983) Electrophrenic respiration following anastomosis of phrenic with branchial nerve in the cat. J Neurosurg 59:262–267

    PubMed  CAS  Google Scholar 

  14. Laroche CM, Mier AK, Spiro SG, Newsom-Davis J, Moxham J, Green M (1989) Respiratory muscle weakness in the Lambert–Eaton myasthenic syndrome. Thorax 44:913–918

    PubMed  CAS  Google Scholar 

  15. Lu L, Haman SP, Ebraheim NA (2002) Vulnerability of the spinal accessory nerve in the posterior triangle of the neck: a cadaveric study. Orthoped 25:71–74

    CAS  Google Scholar 

  16. Midha R (2004) Nerve transfers for severe brachial plexus injuries: a review. Neurosurg Focus 16:1–10

    Article  Google Scholar 

  17. Miller JI, Farmer JA, Stuart W, Apple D (1990) Phrenic nerve pacing of the quadriplegic patient. J Thorac Cardiovasc Surg 99:35–39

    PubMed  CAS  Google Scholar 

  18. Nishino T, Yonezawa T, Honda Y (1983) Properties of spinal accessory nerve activity responses to changes in chemical drive. J Appl Physiol 55:164–168

    PubMed  CAS  Google Scholar 

  19. Nochomovitz ML, Hokins M, Brodkey J, Montenegro H, Mortimer JT, Cherniack NS (1984) Conditioning of the diaphragm with phrenic nerve stimulation after prolonged disuse. Am Rev Respir Dis 130:685–688

    PubMed  CAS  Google Scholar 

  20. Ordronneau J, Despins P, Keravel Y, Cahilleux E, Guiheneuc P, Chollet S (1989) Phrenic stimulation in C1–C2 tetraplegia. Apropos of a case. Rev Mal Respir 6:469–471

    PubMed  CAS  Google Scholar 

  21. Pamphlett R, Murray N, Louda C (1996) Phrenic nerve maturation in the sudden infant death syndrome. Acta Neuropathol 91:422–426

    Article  PubMed  CAS  Google Scholar 

  22. Satomi H, Takahashi K, Aoki M, Kasaba T, Kurosawa Y, Otsuka K (1985) Localization of the spinal accessory motoneurons in the cervical cord in connection with the phrenic nucleus: an HRP study in cats. Brain Res 344:227–230

    Article  PubMed  CAS  Google Scholar 

  23. Treves F (1907) Surgical applied anatomy, 5th edn. Lea Brothers, Philadelphia

    Google Scholar 

  24. Tubbs RS, Salter EG, Oakes WJ (2005) Anatomical landmarks for nerves of the neck: a vade mecum for neurosurgeons. Neurosurgery 56:256–260

    Article  PubMed  Google Scholar 

  25. Tubbs RS (2005) Landmarks for spinal accessory nerve in posterior cervical triangle. J Neurosurgery Spine 3:375–378

    Article  Google Scholar 

  26. Zifko UA, Nicolle MW, Grisold W, Bolton CF (1999) Repetitive phrenic nerve stimulation in myasthenia gravis. Neurology 53:1083–1087

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cell Biology, University of Alabama at Birmingham, Birmingham, AL, USA

    R. Shane Tubbs

  2. Division of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA

    R. Shane Tubbs, Blake Pearson & W. Jerry Oakes

  3. Department of Anatomical Sciences, St. George’s University, Grenada, West Indies

    Marios Loukas

  4. Department of Neurosurgery, Tabriz University of Medical Sciences, Tabriz, Iran

    Ghaffar Shokouhi

  5. Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

    Mohammadali M. Shoja

  6. Pediatric Neurosurgery, Children’s Hospital, 1600 7th Avenue South ACC 400, Birmingham, AL, 35233, USA

    R. Shane Tubbs

Authors
  1. R. Shane Tubbs
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Blake Pearson
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marios Loukas
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ghaffar Shokouhi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mohammadali M. Shoja
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. W. Jerry Oakes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to R. Shane Tubbs.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tubbs, R.S., Pearson, B., Loukas, M. et al. Phrenic nerve neurotization utilizing the spinal accessory nerve: technical note with potential application in patients with high cervical quadriplegia. Childs Nerv Syst 24, 1341–1344 (2008). https://doi.org/10.1007/s00381-008-0650-4

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00381-008-0650-4

Keywords

Search

Navigation