Surgical Technique of Harvesting Vascularized Superficial Radial Nerve Graft

doi:10.1016/j.jhsa.2009.11.018

The Journal of Hand Surgery

Volume 35, Issue 2, February 2010, Pages 312-315

https://doi.org/10.1016/j.jhsa.2009.11.018 Get rights and content

We describe our surgical technique for harvesting the free vascularized superficial radial nerve graft based on the radial artery and its venae comitantes. Anatomy and preoperative preparation are also presented, as well as the indications and some contraindications.

Section snippets

Indications

Currently, our indication for use of a vascularized superficial radial nerve graft in brachial plexus surgery is C5 to C7 paralysis. In such cases, the ulnar nerve is functional and should be preserved. In total brachial plexus palsy reconstruction, when one runs out of other vascularized nerve graft materials, superficial radial nerve can be used. In case of contralateral nerve transfer in brachial plexus surgery, the first choice for vascular nerve graft is the ulnar nerve because of its

Preoperative Preparation

Before harvesting the vascularized superficial radial nerve graft, a careful preassessment is necessary to evaluate the blood supply of the hand. An Allen's test is performed to assess the patency of the ulnar artery and the completeness of the superficial palmar arch. Doppler examination and arteriography of the radial and ulnar arteries should be performed in case of injury or disease.

Vascular Anatomy of Superficial Radial Nerve

According to the anatomic study of the pattern of this extrinsic vascular system by Breidenbach and Terzis,⁴ the superficial radial nerve has an extrinsic blood supply consisting of a single dominant system, radial artery (RA) and its venae comitantes. The RA, one of the terminal branches of the brachial artery, arises in the cubital fossa and passes downward and is laterally overlapped by the brachioradialis muscle. The artery is accompanied by 2 or more venae comitantes. The radial recurrent

Surgical Technique

The patient is placed in a supine position with the shoulder abducted on a separate hand table. The forearm is surgically prepared circumferentially and draped from the mid-arm to the hand. The surgical procedure is performed under pneumatic tourniquet, and the forearm is extended and kept in mid-prone position. The skin is incised in a curvilinear or zigzag fashion along the lateral aspect of the forearm starting from 2 cm proximal to the wrist crease and then extended proximally over the

Complications

In the 20 vascularized superficial radial nerve graft surgeries performed at our center since 2007, none of the patients had any vascular compromise or ischemic complications of the hand. No wound infections of the hand occurred. Two hematomas occurred, but neither required drainage. Careful hemostasis and placement of a surgical drain minimizes hematoma formation. Neuromas, wound separation, and infection are potential complications that are rare if care is taken during dissection and wound

Discussion

Nerve grafting techniques include use of either a free nerve graft or a vascularized nerve graft in the form of pedicle grafts or as a free vascularized graft transfer.⁵ A vascularized nerve graft may be considered for its ability to provide immediate intraneural perfusion in a poorly vascularized bed and to reconstruct large nerve gaps.6, 7

Use of large nerve trunks as free nonvascularized grafts leads to ischemic degeneration and marked fibrosis, which interferes with passage of regenerating

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Cited by (8)

Hand Sensibility after Transradial Arterial Access: An Observational Study in Patients with and without Radial Artery Occlusion
2019, Journal of Vascular and Interventional Radiology
Citation Excerpt :
However, no correlation between this subtle abnormal sensibility and subjective loss of hand function by a validated questionnaire was found. In the per hand analysis, RAO was an independent predictor of abnormal sensibility; however, hampered perfusion after RAO as a cause of neurologic dysfunction is unlikely, as the arteriae nervorum supplying the SRN arise from the radial artery and their takeoff is proximal to the radial puncture side (20). Also, in a previously published study, no reduced hand perfusion or ischemia was found in patients with RAO (21).
To evaluate hand sensibility after transradial access (TRA) in patients with and without radial artery occlusion (RAO).
In this study, 71 patients with and without RAO after TRA for a coronary intervention were studied (79% male, mean age 65 y ± 9). Sensibility testing of both hands was performed with the Semmes-Weinstein monofilaments test. The primary endpoint was abnormal sensibility, defined as diminished sensibility in at least 1 radial nerve–supplied dermatome. The contralateral hand served as control. The influence of TRA, RAO, and clinical characteristics on hand sensibility was evaluated.
In patients with RAO, more abnormal sensibility was observed on the RAO side compared with the control hand (72% vs 17%, P < .01). In patients without RAO, more abnormal sensibility was observed in the TRA hand compared with the control hand (43% vs 10%, P < .01). When analyzing all hands separately, TRA, RAO, and diabetes were independent predictors for abnormal hand sensibility in a multivariate model (odds ratio 3.8, 95% confidence interval 1.4–9.8, P < .01; odds ratio 3.0, 95% confidence interval 1.1–8.5, P = .03; odds ratio 3.5, 95% confidence interval 1.4–8.6, P < .01).
TRA and RAO are associated with diminished hand sensibility.
Use of a harvested radial artery graft with preservation of the vena comitantes to reduce spasm risk and improve graft patency for extracranial to intracranial bypass: Technical note
2016, Clinical Neurology and Neurosurgery
Citation Excerpt :
Selber et al. studied 370 radial forearm flaps between 1998 and 2008 and found that when the venae comitantes has adequate caliber it should be selected as the sole venous outflow for radial forearm flaps [22]. This study and others have shown the importance of appropriate venous drainage to prevent flap failure [12,17,23]. Additionally, beyond simple venous drainage, paired artery-vein complexes may provide each other with physiological equilibrium through the maintenance of a surrounding bio-chemical milieu necessary for the function of the flap.
The vessels of choice for cerebrovascular high-flow direct bypass procedures are the radial artery and the saphenous vein. Radial artery grafts have become favored over saphenous vein grafts because of higher patency rates and better size matching to appropriate recipient vessels. Radial grafts are prone to spasm however, and this may be seen in 4–10% of cases and can be associated with ischemic sequelae. The standard technique for radial artery harvest calls for complete separation of the artery from its adventitial attachments and associated venous network. There is reason to believe that this could contribute to spasm risk and possibly even thrombosis. Radial graft outcomes appear to be improved when the vena comitantes is preserved in cardiac and peripheral applications. We report the novel use of a harvested radial artery graft with preservation of its venae comitantes for extracranial to intracranial bypass.
The patient is a 59-year-old male who had a blunt head trauma with associated loss of consciousness and who was led to the incidental discovery of a large fusiform middle cerebral artery (MCA) aneurysm.
Preservation of the vena comitantes when harvesting a radial arterial graft for bypass, along with dual (arterial and venous) anastomoses, and concomitant use of intra-operative vaso-dilatory maneuvers to prevent spasm, may improve overall graft patency and patient outcome.
Use of a bipedicled nerve flap taken from the dorsum of the digit for reconstruction of neurocutaneous defect in the adjacent finger
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Using our flap, postoperative insufficiency of the blood supply or venous congestion was not noted in all cases. Many clinical studies have demonstrated the superior outcomes achieved using vascularised instead of unvascularised nerve grafts.25–27 Our nerve graft attached with the bipedicled flap is vascularised, because retaining a wide subcutaneous tissue strip between the flap and the nerve graft seems to be adequate to provide blood supply to the nerve.
A digital nerve defect complicated by an associated soft-tissue loss poses a reconstructive challenge. This article reports reconstruction of a similar complex injury using a bipedicled nerve flap including a nerve graft from the dorsal branch of the digital nerve. From July 2008 to May 2010, a retrospective study was conducted with nine consecutive patients who had a combination of soft tissue and digital nerve defects. The injured fingers requiring reconstruction included three index, four middle and two ring fingers. The mean size of the soft-tissue losses was 2.8 × 2.1 cm. The flap is supplied by the digital artery and the venous drainage is by means of a dorsal vein. The mean flap size was 3.1 × 2.3 cm. The nerve gaps were bridged with the nerve graft attached with the flap. The average length of the nerve grafts was 3.0 cm. All flaps survived completely, and the defects were reconstructed successfully. Venous congestion was not observed in our series. At a mean follow-up period of 23 months, the average scores of static two-point discrimination (2PD) and Semmes–Weinstein monofilament on the finger pulp of the injured side were 7.5 mm and 3.93, respectively. The donor site morbidity was acceptable. According to the Michigan Hand Outcomes Questionnaire, four patients were strongly satisfied and five were satisfied with functional recovery of the injured finger. The bipedicled nerve flap is a safe and effective option for reconstruction of complex digital injury involving soft tissue and nerve defects. Our technique has been shown to provide sufficient sensory recovery.
ClinicalTrials.gov ID: NCT01707654.
Type of study/level of evidence: Therapeutic IV.
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2023, Journal of Clinical Medicine
Brachial plexus injury: Recent diagnosis and management
2021, Open Access Macedonian Journal of Medical Sciences
The role of vascularization in nerve regeneration of nerve graft
2020, Neural Regeneration Research

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Surgical techniqueSurgical Technique of Harvesting Vascularized Superficial Radial Nerve Graft

Section snippets

Indications

Preoperative Preparation

Vascular Anatomy of Superficial Radial Nerve

Surgical Technique

Complications

Discussion

Hand Clin

J Hand Surg

J Hand Surg

Hand Clin

The free vascularized nerve graftA further experimental and clinical application of microvascular techniques

Plast Reconst Surg

Vascularized nerve graft: an experimental and clinical review

Ann Plast Surg

Surgical technique
Surgical Technique of Harvesting Vascularized Superficial Radial Nerve Graft