Fascicular Selection for Nerve Transfers: The Role of the Nerve Stimulator When Restoring Elbow Flexion in Brachial Plexus Injuries

doi:10.1016/j.jhsa.2011.08.017

The Journal of Hand Surgery

Volume 36, Issue 12, December 2011, Pages 2002-2009

https://doi.org/10.1016/j.jhsa.2011.08.017 Get rights and content

Purpose

Restoration of elbow flexion is an important goal in brachial plexus injuries. Double nerve transfers using fascicles from ulnar and median nerves have consistently produced good results without causing functional compromise to the donor nerve. According to conventional practice, these double nerve transfers are dependent on the careful isolation of ulnar and median nerve fascicles, which are responsible for wrist flexion, using a handheld nerve stimulator. Here we suggest that fascicular selection by nerve stimulation might not be a necessity when executing double nerve transfers for restoration of elbow flexion in brachial plexus injuries.

Methods

This is a retrospective case control study in 26 patients with C5, C6 brachial plexus injuries that were managed with double nerve transfers between March 2005 and January 2008. Our technique consisted of transferring 2 fascicles, one each from the ulnar and the median nerve, directly onto the biceps and brachialis motor branches. Contrary to the standard practice, the ulnar or median nerve fascicles were selected without using a handheld nerve stimulator. Results were compared to 21 cases (control group) in which a nerve stimulator was used for fascicular selection. The denervation period ranged from 3 to 9 months.

Results

Twenty-four patients of the study group experienced full restoration of elbow flexion, and 2 had an antigravity flexion of 120° and 110°. The EMG revealed the first sign of reinnervation of biceps and brachialis muscle at 9 ± 2 weeks and 11 ± 2 weeks, as compared to 9 ± 2 weeks and 12 ± 4 weeks in the control group. After surgery, the appearance of initial evidence of elbow flexion, the range and mean of elbow flexion strength, and the difference between preoperative and postoperative grip and pinch strengths were comparable in both groups. At 24 to 28 months follow-up, 19 patients of the study group had M4 power and 7 had M3, compared to 18 and 3 cases, respectively, in the control group. The P values for Medical Research Council grade, strength of elbow flexion, and range of elbow flexion between the 2 groups did not reveal any significant statistical difference.

Conclusions

Double nerve transfer is a reliable technique for restoring elbow flexion in brachial plexus injuries. There is no advantage of using a nerve stimulator in selecting fascicles before performing the nerve transfer.

Type of study/level of evidence

Therapeutic III.

Section snippets

Study group

The study included 26 consecutive, male patients with C5, C6 brachial plexus injuries who had not recovered 3 months after injury. Their average age was 25 years (range, 18 to 39 years). Eleven patients had C5 and C6 root avulsions (level 1 injury), and 15 patients had diffuse upper truncal fibrosis with doubtful viability of the originating roots (level 2 injury). The denervation period (interval between injury and repair surgery) ranged from 3 to 9 months.

The patients who presented later than

Preoperative assessment

The preoperative muscle power of the biceps and brachialis muscles in both the groups was graded as M0 on the MRC scale. Active elbow flexion ranged from 0° to 10°. Preoperative grip strengths in the study and control groups averaged 25.1 kg and 26.5 kg, respectively. Preoperative pinch strengths in the study and control groups averaged 7.3 kg and 7.4 kg, respectively.

Results of double nerve transfers

Elbow flexion was restored in all 26 patients of the study group and in 21 of the control group. Following nerve transfer

Discussion

Restoration of elbow flexion is an important goal in the management of devastating upper brachial plexus injuries.¹ Reinnervation of the elbow flexors offer superior results compared to muscle or tendon transfers.19, 20 Transfer of ulnar and median nerve fascicles to the target branches have consistently yielded good results and have surpassed other procedures.14, 15, 16, 21 Most authors13, 14, 15, 16 emphasize the importance of careful selection of donor fascicles to avoid the more vital motor

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Cited by (12)

The Effectiveness of Different Nerve Transfers in the Restoration of Elbow Flexion in Adults Following Brachial Plexus Injury: A Systematic Review and Meta-Analysis
2023, Journal of Hand Surgery
Restoration of elbow flexion is an important goal in the treatment of patients with traumatic brachial plexus injury. Numerous studies have described various nerve transfers for neurotization of the musculocutaneous nerve (or its motor branches); however, there is uncertainty over the effectiveness of each method. The aim of this study was to summarize the published evidence in adults with traumatic brachial plexus injury.
Medline, Embase, medRxiv, and bioRxiv were systematically searched from inception to April 12, 2021. We included studies that reported the outcomes of nerve transfers for the restoration of elbow flexion in adults. The primary outcome was elbow flexion of grade 4 (M4) or higher on the British Medical Research Council scale. Data were pooled using random-effects meta-analyses, and heterogeneity was explored using metaregression. Confidence intervals (CIs) were generated to the 95% level.
We included 64 articles, which described 13 different nerve transfers. There were 1,335 adults, of whom 813 (61%) had partial and 522 (39%) had pan-plexus injuries. Overall, 75% of the patients with partial brachial plexus injuries achieved ≥M4 (CI, 69%–80%), and the choice of donor nerve was associated with clinically meaningful differences in the outcome. Of the patients with pan-plexus injuries, 45% achieved ≥M4 (CI, 31%–60%), and overall, each month delay from the time of injury to reconstruction reduced the probability of achieving ≥M4 by 7% (CI, 1%–12%).
The choice of donor nerve affects the chance of attaining a British Medical Research Council score of ≥4 in upper-trunk reconstruction. For patients with pan-plexus injuries, delay in neurotization may be detrimental to motor outcomes.
Therapeutic IV.
Fascicle-Specific Targeting of Longitudinal Intrafascicular Electrodes for Motor and Sensory Restoration in Upper-Limb Amputees
2021, Hand Clinics
Citation Excerpt :
Although the deep motor fascicle of the ulnar nerve and the thenar motor fascicle of the median nerve are not present at these more proximal levels, the medial cord and lateral cord contributions to the median nerve provide a convenient anatomic site where sensory and motor axons are segregated into discrete fascicles and available for FAST-LIFE targeting. At these levels, the ulnar nerve also contains discrete intraneural fascicles15 that can be individually targeted with FAST-LIFE electrodes to provide high channel counts for high DoF prosthetic control and functional redundancy for long-term interfacing robustness. Conventional and experimental approaches that use EMG of the forearm or hand muscles for myoelectric prosthesis control obviously cannot be used alone at the transhumeral and glenohumeral levels, because of the total absence of the muscles that would supply EMG control signals.
The modern concept of the bundle structure of the brachial plexus and nerves of the upper limb
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2021, Peripheral Nerve Issues after Orthopedic Surgery: A Multidisciplinary Approach to Prevention, Evaluation and Treatment
Double Fascicular Transfer Using Partially Injured Donor Nerves: Is It Powerful Enough to Restore Elbow Flexion in Acute Brachial Plexus Injuries?
2021, Journal of Reconstructive Microsurgery
Outcomes of Single versus Double Fascicular Nerve Transfers for Restoration of Elbow Flexion in Patients with Brachial Plexus Injuries: A Systematic Review and Meta-Analysis
2019, Plastic and Reconstructive Surgery

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Scientific articleFascicular Selection for Nerve Transfers: The Role of the Nerve Stimulator When Restoring Elbow Flexion in Brachial Plexus Injuries

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Study group

Preoperative assessment

Results of double nerve transfers

Discussion

Surgical treatment of traction injuries of the brachial plexus

Clin Orthop Relat Res

Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury)

J Hand Surg

Transfer of the medial pectoral nerve: Myth or reality?

Neurosurgery

Transfer of thoracodorsal nerve to musculocutaneous or axillary nerve in old traumatic injury

J Hand Surg

Intercostal nerve transfer for brachial plexopathy

J Hand Surg

Intercostal nerve transfer of the musculocutneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients

J Hand Surg

Satisfactory elbow flexion in complete (preganglionic) brachial plexus injuries; produced by suture of third and fourth intercostal nerves to musculocutaneous nerve

J Hand Surg

Direct nerve crossing with the intercostals nerve to treat avulsion injuries of the brachial plexus

J Hand Surg

Intercostal nerve crossing to restore elbow flexion and sensibility of the hand for a root avulsion type of brachial plexus injury

Microsurgery

Neurotization via the spinal accessory nerve in complete paralysis due to multiple avulsion injuries of the brachial plexus

Clin Orthop Relat Res

Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus

J Hand Surg

Nerve transfers to biceps muscle using part of ulnar nerve for C5-C6 avulsion of the brachial plexus; anatomical study and report of four cases

J. Hand Surg

Ulnar nerve fascicle transfer on to the biceps muscle nerve in C5-C6 or C5-C6-C7 avulsions of the brachial plexus: Eighteen cases

Ann Chir Main Memb Super

Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion

J. Hand Surg

Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies

Plast Reconstr Surg

Comparison of single versus double nerve transfers for elbow flexion after brachial plexus injury

Plast Reconstr Surg

Scientific article
Fascicular Selection for Nerve Transfers: The Role of the Nerve Stimulator When Restoring Elbow Flexion in Brachial Plexus Injuries