Long Thoracic Nerve Neurotization for Restoration of Shoulder Function in C5-7 Brachial Plexus Preganglionic Injuries: Case Report

doi:10.1016/j.jhsa.2010.05.024

The Journal of Hand Surgery

Volume 35, Issue 9, September 2010, Pages 1427-1431

https://doi.org/10.1016/j.jhsa.2010.05.024 Get rights and content

C5-7 brachial plexus preganglionic injuries are usually associated with complete paralysis of the long thoracic nerve. This makes it difficult to provide satisfactory shoulder function by neurotizing only the suprascapular nerve, compared with C5 and C6 preganglionic injuries, in which the long thoracic nerve is spared. We present a case report of a 21-year-old man who sustained a C5-7 brachial plexus preganglionic injury and obtained excellent shoulder function by intercostal nerve transfer to the long thoracic nerve in addition to neurotization of the suprascapular nerve. Our report emphasizes the importance of restoring the activity of the long thoracic nerve.

Section snippets

Case report

A 20-year-old right-handed man sustained a left brachial plexus injury when being tackled while playing football. He was referred to our clinic for further treatment 5 weeks after injury.

Discussion

A lot of confusion and misunderstandings exist in upper-type brachial plexus injury concerning preoperative evaluation and postoperative functional outcomes. The most critical point is that preoperative paralysis is not classified strictly according to the level of injury and number of the injured root, although Hentz and Doi¹⁰ stated that there are marked differences in outcomes between C5 and C6 and the C5, C6, and C7 preganglionic injuries. The spinal accessory nerve is the donor nerve of

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Cited by (11)

Treatment of Complete Brachial Plexus Injuries Using Double Free Muscle Transfer
2023, Journal of Hand Surgery
The purpose of this study was to examine the surgical outcomes of double free muscle transfer (DFMT) performed in patients with complete brachial plexus injury (BPI).
We retrospectively analyzed the outcomes of DFMT for 12 patients with complete BPI who were followed up for more than 2 years after the final muscle transplantation. Their mean age was 29 years (range, 18–41). Three patients underwent contralateral C7 nerve root transfer before the DFMT. The range of motion (ROM) of the shoulder, elbow, and fingers was measured. Patient-reported outcome measures, including Disability of the Shoulder, Arm, and Hand (DASH) scores and visual analog scale (VAS) scores for pain, were also examined.
The mean shoulder ROM against gravity was 22° ± 8° in abduction and 33° ± 5° in flexion. Seven patients underwent phrenic nerve (PhN) transfer to the suprascapular nerves, and five exhibited asymptomatic lung impairment on spirography more than 2 years after PhN transfer. The mean elbow ROM against gravity was 111° ± 9° in flexion and –32° ± 7° in extension. All patients obtained elbow flexion >90° against a 0.5-kg weight. All patients obtained touch sensation and two recognized warm and cold sensations in the affected palm. The mean total active motion of the affected fingers was 44° ± 11°. All patients exhibited hook function of the hands. The mean preoperative and postoperative DASH scores were 70.3 ± 13.4 and 51.8 ± 15.9, respectively. The mean pain VAS score was 28 ± 31 at the final follow-up.
Double free muscle transfer provided patients with complete brachial plexus palsy with good elbow flexion and hand hook functions.
Therapeutic IV.
Nerve transfers in the upper extremity: A review
2020, Injury
Citation Excerpt :
They didn't repair the axillary nerve, as in their opinion the deltoid muscle is not a main abductor of the shoulder joint and can be supplemented by other shoulder girdle muscles. In their case presentation with two years follow up, the patient had no scapular winging, achieved 180 degrees of shoulder flexion, 180 degrees of abduction and 60 degrees of external rotation [29]. Combined Nerve Transfers: After the improved results of Oberlin in a double transfer for elbow flexion, Somsak Leechavengvongs, one of his trainees, described in 2003 the concept of a double nerve transfer for restoration of function of the shoulder joint.
Injury of the brachial plexus and peripheral nerve often result in significant upper extremity dysfunction and disability. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries. These transfers require an intimate knowledge of nerve topography, a technically demanding Intraneural dissection and require extensive physical therapy for retraining. In this review, we present a summary of the most widely accepted nerve transfers in the upper extremity described in the current literature.
Polyester tape scapulopexy for chronic upper extremity brachial plexus injury
2015, Journal of Hand Surgery
Citation Excerpt :
They concluded that repair of the long thoracic nerve was mandatory to achieve optimum shoulder function. Yamada et al9 reported a case of long thoracic nerve transfer for restoration of shoulder function in C5 to C7 brachial plexus preganglionic injuries. They concluded that the suprascapular nerve was the first priority and that the long thoracic nerve rather than the axillary nerve was the second priority in shoulder reconstruction of C5, C6, and C7 preganglionic injuries.
To report the results of scapular stabilization for winging in patients with chronic upper brachial plexus injury.
Eight patients, mean age 36 years, who had a winged scapula after successful restoration of major shoulder function by nerve transfer underwent scapular stabilization to the ribcage using polyester tape. The follow-up period ranged from 24 to 40 months (mean, 38 mo). Data collection included radiographic analysis, active range of motion measurement, University of California Los Angeles shoulder score, and visual analog scale pain score.
All patients had clinical improvement with resolution of scapular winging. Five patients had no winging and 3 had mild winging after the surgery. Mean active forward flexion increased from 101° preoperatively to 127° postoperatively. Mean active shoulder abduction increased from 91° preoperatively to 121° postoperatively. Mean University of California Los Angeles shoulder score improved from 17 to 27 and mean visual analog scale pain score improved from 6.1 to 0.7. In addition, mean lateral deviated angle increased from 4° from neutral preoperatively to 9° at the last follow-up. All patients reported satisfaction with postoperative appearance.
Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers.
Therapeutic IV.
Intercostal Nerve Harvest in Brachial Plexus Injuries
2021, Operative Brachial Plexus Surgery: Clinical Evaluation and Management Strategies
Management of C5–7 Injuries
2021, Operative Brachial Plexus Surgery: Clinical Evaluation and Management Strategies
Elbow flexion reanimation
2019, JBJS Reviews

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: The authors are grateful to Dr. Abhijeet L. Wahegaonkar, MD, for assistance with editing this article.

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Scientific articleLong Thoracic Nerve Neurotization for Restoration of Shoulder Function in C5-7 Brachial Plexus Preganglionic Injuries: Case Report

Section snippets

Case report

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers

Plast Reconstr Surg

Suprascapular nerve reconstruction in 118 cases of adult posttraumatic brachial plexus

Plast Reconstr Surg

Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury

J Reconstr Microsurg

Biomechanics of the shoulder

Scientific article
Long Thoracic Nerve Neurotization for Restoration of Shoulder Function in C5-7 Brachial Plexus Preganglionic Injuries: Case Report