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Intercostal to musculocutaneous nerve transfer in patients with complete traumatic brachial plexus injuries: case series

  • Original Article - Peripheral Nerves
  • Published:
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Abstract

Background

To recover biceps strength in patients with complete brachial plexus injuries, the intercostal nerve can be transferred to the musculocutaneous nerve. The surgical results are very controversial, and most of the studies with good outcomes and large samples were carried out in Asiatic countries. The objective of the study was to evaluate biceps strength after intercostal nerve transfer in patients undergoing this procedure in a Western country hospital.

Methods

We retrospectively analyzed 39 patients from 2011 to 2016 with traumatic brachial plexus injuries receiving intercostal to musculocutaneous nerve transfer in a rehabilitation hospital. The biceps strength was graded using the British Medical Research Council (BMRC) scale. The variables reported and analyzed were age, the time between trauma and surgery, surgeon experience, body mass index, nerve receptor (biceps motor branch or musculocutaneous nerve), and the number of intercostal nerves transferred. Statistical tests, with a significance level of 5%, were used.

Results

Biceps strength recovery was graded ≥M3 in 19 patients (48.8%) and M4 in 15 patients (38.5%). There was no statistical association between biceps strength and the variables. The most frequent complication was a pleural rupture.

Conclusions

Intercostal to musculocutaneous nerve transfer is a safe procedure. Still, biceps strength after surgery was ≥M3 in only 48.8% of the patients. Other donor nerve options should be considered, e.g., the phrenic or spinal accessory nerves.

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Abbreviations

BMRC:

British Medical Research Council Scale

BMI:

Body Mass Index

References

  1. Bhardwaj P, Bhardwaj N (2009) Motor grading of elbow flexion - is Medical Research Council grading good enough? J Brachial Plex Peripher Nerve Inj 4:3. https://doi.org/10.1186/1749-7221-4-3

    Article  PubMed  PubMed Central  Google Scholar 

  2. Brophy RH, Wolfe SW (2005) Planning brachial plexus surgery: treatment options and priorities. Hand Clin 21:47–54. https://doi.org/10.1016/j.hcl.2004.09.007

    Article  PubMed  Google Scholar 

  3. Cardoso M d M, Gepp R d A, Mamare E, Guedes-Correa JF (2018) Results of phrenic nerve transfer to the musculocutaneous nerve using video-assisted thoracoscopy in patients with traumatic brachial plexus injury: series of 28 cases. Oper Neurosurg. https://doi.org/10.1093/ons/opy350

  4. Chalidapong P, Sananpanich K, Klaphajone J (2006) Electromyographic comparison of various exercises to improve elbow flexion following intercostal nerve transfer. J Bone Joint Surg (Br) 88-B:620–622. https://doi.org/10.1302/0301-620x.88b5.17360

    Article  Google Scholar 

  5. Cho AB, Iamaguchi RB, Silva GB, Paulos RG, Kiyohara LY, Sorrenti L, de Menezes K d OCRT, de Rezende MR, Wei TH, Mattar Júnior R (2015) Intercostal nerve transfer to the biceps motor branch in complete traumatic brachial plexus injuries. Microsurgery 35:428–431. https://doi.org/10.1002/micr.22453

    Article  PubMed  Google Scholar 

  6. Giddins GE, Kakkar N, Alltree J, Birch R (1995) The effect of unilateral intercostal nerve transfer upon lung function. J Hand Surg (Br) 20:675–676

    Article  CAS  Google Scholar 

  7. Hill B, Williams G, Olver J, Bialocerkowski A (2015) Do existing patient-report activity outcome measures accurately reflect day-to-day arm use following adult traumatic brachial plexus injury? J Rehabil Med 47:438–444. https://doi.org/10.2340/16501977-1950

    Article  PubMed  Google Scholar 

  8. Kim DH, Murovic JA, Tiel RL, Kline DG (2004) Mechanisms of injury in operative brachial plexus lesions. Neurosurg Focus 16:E2

    PubMed  Google Scholar 

  9. Kovachevich R, Kircher MF, Wood CM, Spinner RJ, Bishop AT, Shin AY (2010) Complications of intercostal nerve transfer for brachial plexus reconstruction. J Hand Surg [Am] 35:1995–2000. https://doi.org/10.1016/j.jhsa.2010.09.013

    Article  Google Scholar 

  10. Krakauer JD, Wood MB (1994) Intercostal nerve transfer for brachial plexopathy. J Hand Surg [Am] 19:829–835. https://doi.org/10.1016/0363-5023(94)90196-1

    Article  CAS  Google Scholar 

  11. Liu Y, Lao J, Zhao X (2015) Comparative study of phrenic and intercostal nerve transfers for elbow flexion after global brachial plexus injury. Injury 46:671–675. https://doi.org/10.1016/j.injury.2014.11.034

    Article  PubMed  Google Scholar 

  12. Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY (2017) Free functioning gracilis muscle transfer with and without simultaneous intercostal nerve transfer to Musculocutaneous nerve for restoration of elbow flexion after traumatic adult brachial pan-plexus injury. J Hand Surg [Am] 42:293.e1–293.e7. https://doi.org/10.1016/j.jhsa.2017.01.014

    Article  Google Scholar 

  13. Malessy MJA, Thomeer RTWM (2009) Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery. J Neurosurg 88:266–271. https://doi.org/10.3171/jns.1998.88.2.0266

    Article  Google Scholar 

  14. Maricq C, Jeunehomme M, Mouraux D, Rémy P, Brassinne E, Bahm J, Schuind F (2014) Objective evaluation of elbow flexion strength and fatigability after nerve transfer in adult traumatic upper brachial plexus injuries. Hand Surg 19:335–341. https://doi.org/10.1142/S0218810414500245

    Article  PubMed  Google Scholar 

  15. Mendonça Cardoso M, Gepp R, Correa JFG (2016) Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review. Acta Neurochir 158:1793–1800. https://doi.org/10.1007/s00701-016-2855-8

    Article  PubMed  Google Scholar 

  16. Merrell GA, Barrie KA, Katz DL, Wolfe SW (2001) Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg [Am] 26:303–314. https://doi.org/10.1053/jhsu.2001.21518

    Article  CAS  Google Scholar 

  17. Moiyadi AV, Devi BI, Sivaraman Nair KP (2008) Brachial plexus injuries: outcome following neurotization with intercostal nerve. J Neurosurg 107:308–313. https://doi.org/10.3171/jns-07/08/0308

    Article  Google Scholar 

  18. Nuttall FQ (2015) Body mass index: obesity, BMI, and health: a critical review. Nutr Today 50:117–128. https://doi.org/10.1097/NT.0000000000000092

    Article  PubMed  PubMed Central  Google Scholar 

  19. Ruch DS, Friedman A, Nunley JA (1995) The restoration of elbow flexion with intercostal nerve transfers. Clin Orthop Relat Res 314:95–103

  20. Shyam A, Doshi P, Shah V, Bhatia A (2011) Nerve reconstruction: a cohort study of 93 cases of global brachial plexus palsy. Indian J Orthop 45:153. https://doi.org/10.4103/0019-5413.77136

    Article  PubMed  PubMed Central  Google Scholar 

  21. Siqueira MG, Martins RS (2009) Phrenic nerve transfer in the restoration of elbow flexion in brachial plexus avulsion injuries: how effective and safe is it? Neurosurgery 65:A125–A131. https://doi.org/10.1227/01.NEU.0000338865.19411.7F

    Article  PubMed  Google Scholar 

  22. Socolovsky M, Paez M (2013) A literature review of intercostal-to-musculocutaneous-nerve transfers in brachial plexus injury patients: does body mass index influence results in Eastern versus Western countries? Surg Neurol Int 4:152. https://doi.org/10.4103/2152-7806.122233

    Article  PubMed  PubMed Central  Google Scholar 

  23. Terzis JK, Barbitsioti A (2012) Primary restoration of elbow flexion in adult post-traumatic plexopathy patients. J Plast Reconstr Aesthet Surg 65:72–84. https://doi.org/10.1016/j.bjps.2011.08.029

    Article  PubMed  Google Scholar 

  24. Vathana T, Larsen M, De Ruiter GCW, Bishop AT, Spinner RJ, Shin AY (2007) An anatomic study of the spinal accessory nerve: extended harvest permits direct nerve transfer to distal plexus targets. Clin Anat 20:899–904. https://doi.org/10.1002/ca.20545

    Article  PubMed  Google Scholar 

  25. Waikakul S, Wongtragul S, Vanadurongwan V (1999) Restoration of elbow flexion in branchial plexus avulsion injury: comparing spinal accessory nerve transfer with intercostal nerve transfer. J Hand Surg [Am] 24:571–577. https://doi.org/10.1053/jhsu.1999.0571

    Article  CAS  Google Scholar 

  26. Wilcox M, Brown H, Johnson K, Sinisi M, Quick TJ (2019) An assessment of fatigability following nerve transfer to reinnervate elbow flexor muscles. Bone Joint J 101-B:867–871. https://doi.org/10.1302/0301-620X.101B7.BJJ-2019-0005.R1

    Article  CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals, SMHS501, Brasilia, 70335-901, Brazil

    Marcio de Mendonça Cardoso & Ricardo Gepp

  2. Department of Neurological Surgery, Instituto Hospital de Base do Distrito Federal, Brasilia, Brazil

    Flávio Leão Lima

  3. Sarah Network of Rehabilitation Hospitals, Brasilia, Brazil

    Andreia Gushiken

Authors
  1. Marcio de Mendonça Cardoso
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  2. Ricardo Gepp
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  3. Flávio Leão Lima
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  4. Andreia Gushiken
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Corresponding author

Correspondence to Marcio de Mendonça Cardoso.

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Comments

This paper by Cardoso et al evaluates the outcomes of a cohort of patients with panplexal injury treated with intercostal nerve transfer for elbow flexion. The technique has been a work horse for more than 50 years and was popularized by Asian colleagues. This report provides an honest assessment of a standard nerve transfer performed in a leading center in South America.

Elbow flexion is the number one priority of brachial plexus reconstruction. It relies on 'nerve economics'. In complete injury, there are few resources, so they must be used wisely. Options include nerve grafting from any available nerve stumps; and/or nerve transfers: intercostals (ICN) and spinal accessory (SAN) being standard and phrenic and contralateral C7 nerves, more aggressive.

These authors use a standard protocol of ICNs and SAN transfers to obtain elbow flexion and shoulder stability. M3 or greater elbow flexion was achieved in 48.8% of their adult patients treated with ICN transfer. While this result may be lower than other well cited publications of nerve transfers using ICNs or other donors for elbow flexion (summarized in several recent meta-analyses), it is within range of what many other groups describe. Still, M3 function, while a reasonable result for the surgeon, is not particularly useful for the patient. In general, M4 elbow flexion should be the goal as it what patients need to perform most activities of daily living. M4 was achieved in 38.5% with this technique. In patients with panplexal injury, our group has been employing a novel technique of dual reinnervation using 4 ICNs: 2 to the native biceps and 2 to a free functioning muscle transfer for elbow flexion (and/or finger flexion) (1).

The paper highlights two major points (and opportunities) in the state of the art in the reconstruction of patients with complete brachial plexus injury:1. Given the limited available donors, how do we achieve the best outcome given the many variables (i.e., time from injury, age of patient, body mass index, and other injuries). What nerve transfer and what specific technique should we use to what recipient in which patient?2. What is the best outcome assessment? Clearly MRC is not scientifically rigid enough. Should we routinely be including other measures, such as dynamometry, endurance, and patient satisfaction scores?

Through international efforts as this, we can combine efforts to try to design the best mouse trap.

Robert J. Spinner,

Rochester, MN,USA

Reference:

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 plexus pan-plexus injury. Plast Reconstr Surg 2016;483e-8e.

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de Mendonça Cardoso, M., Gepp, R., Lima, F.L. et al. Intercostal to musculocutaneous nerve transfer in patients with complete traumatic brachial plexus injuries: case series. Acta Neurochir 162, 1907–1912 (2020). https://doi.org/10.1007/s00701-020-04433-3

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  • DOI: https://doi.org/10.1007/s00701-020-04433-3

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