C5 C6 Nerve Transfers for Brachial Plexus Injury

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Brachial Plexus repair with Nerve transfer.

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C5 C6 Nerve Transfers for Brachial Plexus Injury

  1. 1. Scientific Article | The Role of Nerve Transfers for C5-C6 Brachial Plexus Injury in Adults Matthew J. Schessler, MS-III instrumentation, coupled with further investigators in three ways. First, West Virginia University School of understanding of nerve anatomy, DaVinci approached the human Medicine significant strides have been made cadaver in a methodical fashion, W.Thomas McClellan, M.D. Plastic and Upper Extremity Surgeon to improve nerve transfer outcome. noting every anatomical nuance. Morgantown Plastic Surgery Associates Secondly, his mechanical prowess led him to postulate on the function History of Brachial Plexus of that which he was dissecting. Abstract Injuries and Reconstruction Finally and most importantly he The brachial plexus consists of nerve Brachial plexus injuries have used his artistic talent to create a roots C5 – T1. Upper brachial plexus roots (C5-C6) innervate proximal muscles been a reported directly or detailed and vibrant anatomical of the shoulder and upper arm. Injuries indirectly for the last 2800 years. reference for future work. causing root avulsion or rupture require The first mention of a brachial In 1824 French physiologist Marie intensive treatment and significantly plexus injury in literature occurs in Jean Pierre Flourens was the first to impact patients’ quality of life. Nerves Homer’s The Iliad around 800BC.1 theorize that an injured nerve could regenerate extremely slowly and without Although sporadic mention of be bypassed, “joining the superior treatment, patients with upper brachial plexus injuries is scattered in the end of one nerve with the inferior end plexus lesions may lose motor function distal to the injury. Upper brachial plexus early literature little anatomical of the other and visa versa.”3-4 reconstruction using nerve transfers is a dissection or description took place But it wasn’t until 1948 when new method to bypass damaged areas during the next thousand years. Alexander Lurje, a Russian surgeon, thereby allowing patients to regain critical In 1507 Leonardo DaVinci performed the first brachial arm functions faster. We present a review performed a detailed dissection plexus reconstruction using nerve of brachial plexus cadaveric anatomy, of a 100 year old man who had transfers on a 20 year old female reconstruction transfer techniques, and management. died of natural causes. This initial injured by a Nazi bomb blast.5 experience led him to sketch the Remarkably he was able to perform Introduction now famous illustrations entitled the procedure prior to the advent “del Vecchio” and perform over of microsurgical equipment, The upper brachial plexus 30 detailed human dissections. instruments, or technique. roots (C5-C6) innervate proximal DaVinci’s impact on modern Over the last 20 years our arm muscles controlling shoulder anatomy differed from prior improved understanding of nerve abduction, elbow flexion and contribute to the innervation of distal muscles controlling limb function. Upper root avulsions are devastating Figure 1. injuries because the patient loses Description and artist’s rendition of Hector’s altercation with Teucer resulting in the critical functions of shoulder a brachial plexus injury.1 abduction and elbow flexion. Even “Hector sprang from his chariot to if distal innervation is unaffected the ground, and seizing a great stone (C7-T1), without shoulder and elbow made straight for Teucer with intent stability the wrist and hand cannot to kill him…Hector struck him with perform daily activities. Repairing the jagged stone….he hit him where these avulsed roots presents a the collar bone divides the neck from the chest, a very deadly place and challenging scenario to any surgeon broke the sinew of his arm so that his due to the complexities of nerve wrist was less, and his bow dropped regeneration, nerve transfer, and the from his hand as he fell forward on surgical techniques themselves. The his knees.” first brachial plexus nerve transfer - Homer, The Iliad, c. 800BC occurred in 1948. With the advent of improved microsurgical technique, 12 West Virginia Medical Journal
  2. 2. | Scientific Article Cold Beer.” The five terminal nerve Figure 2. branches are the musculocutaneous, Leonardo da Vinci’s representation of the brachial plexus.2 axillary, radial, median, and ulnar nerves. Other nerves originate from “The nerve branches with their various locations on the plexus. muscles serve the nerve chords as soldiers serve their officers, The pertinent anatomy for and the nerve chords serve this paper includes the roots, the the ‘sensus communis’ as the superior trunk, the suprascapular officers serve their captain, and nerve, and the terminal branch the ‘sensus communis’ serves the soul as the captain serves his nerves. Please see figures 3 and 4 lord.” for an anatomical diagram and table - Leonardo da Vinci, c. 1508 summarizing nerves and function. Brachial plexus injuries usually involve either pre-ganglionic avulsion or post-ganglionic rupture.pathophysiology, anatomy, and It originates from the C5-T1 spinal Avulsion occurs when the nerve rootrepair has led to advances in nerve roots (ventral rami). It is is torn from the spinal cord. Rupturethe treatment options for upper further divided into three trunks, occurs when the nerve is damagedbrachial plexus trauma. six divisions (three anterior and or transected distal to the dorsal three posterior), three cords, and root ganglion but its attachmentAnatomy finally into five terminal nerve to the spinal cord is intact. There Understanding the anatomy of branches. Medical students keep are classifications of nerve injurythe brachial plexus is important in these components straight using from Sunderland and Seddonorder to perform a nerve transfer. the acronym “Robert Taylor Drinks beyond the scope of the review.6,7 A West Virginia company bringing quality home infusion services to your home! Complete Home Infusion Services Antibiotics & Antimicrobials | Parenteral Nutrition Enteral Nutrition | Hydration | Pain Management | Chemotherapy Pediatric Therapy | Injectables | Inotropic Therapy Immunoglobulin | Other Specialty Infusion Medications Pumps & Supplies 1111A Jefferson Road South Charleston, WV 25309 304.414.3660 telephone 800.531.2304 toll free msvitalcare.com January/February 2010 | Vol. 106 13
  3. 3. Scientific Article | Figure 3. been lost and what functions are Anatomical diagram of the brachial plexus. Also shown is the spinal accessory nerve (XI). most critical to regaining the highest quality of life can be established. The physical exam is one of the best diagnostic tools to formulate the exact pattern of injury. The patient’s strength and range of motion should be observed and a Tinel’s test performed.8 Serial electromyelographs (EMG) and CT myelograms are required prior to brachial plexus exploration. Typically the first EMG is performed three months following trauma and a second EMG is performed five months following injury. If no progress is identified on the EMG or during the physical exam then a CT myelogram is obtained and plexus exploration performed. Post-ganglionic rupture injuries are amenable to grafting whereas pre- ganglionic avulsion injuries require nerve transfer. Pre-ganglionic root avulsion is not amenable to direct repair and nerve transfer remains the best option. Some injuries avulse or rupture 80-100% of the plexus roots. These patients are not good Figure 4. candidates for nerve transfer due Summary of pertinent nerves arising from the brachial plexus, major target muscles, to the loss of the lower motor roots and functions. typically used for transfer. Often these are treated with nerve grafts Important Nerves for Upper Brachial plexus Injury and reconstruction from the phrenic, intercostal, or Nerve Major muscles innervated Important functions contra-lateral brachial plexus.8 Musculocutaneous Biceps brachii, brachialis mm. Elbow flexion Concepts of Brachial Plexus Axillary  Deltoid m.  Shoulder abduction & stability Reconstruction Suprascapular  Supraspinatus m.  Shoulder abduction & stability Many studies document nerve regeneration following injury; Radial Triceps brachii, wrist/hand extensors Elbow, wrist, & finger extension however the absolutes regarding Median Wrist flexors, hand muscles Wrist flexion, hand function recovery remain elusive. We know that once the nerve begins to Ulnar Wrist flexors, hand muscles Wrist flexion, hand function regenerate it moves at about 1-1.5 mm daily.9 The motor endplates Physical Exam head is forcefully distracted from the with which the nerve communicates Supraclavicular rupture or ipsilateral shoulder.8 This manner of will eventually cease to function in avulsion accounts for about 70% forceful separation typically results 12-18 months. If a proximal plexus of brachial plexus injuries and in pre-ganglionic root avulsion or injury occurs, then the regenerated among these the upper roots are post-ganglionic rupture of the upper nerve may not reach the motor involved 70% of the time. Most of roots (C5-C6) while sparing the lower end plate in time to be effective. these injuries occur in motorcycle roots (C7, C8, T1). By performing a Salvage of critical motor end plates or other high speed personal detailed physical exam an operative and their corresponding muscles transportation accidents in which the plan based on what functions have may be facilitated with the transfer 1 West Virginia Medical Journal
  4. 4. | Scientific ArticleFigure 5.Intraoperative photographs during a double Oberlin procedure showing the identification of redundant ulnar and median nervefascicles (left) and their coaptation to the brachialis and biceps muscles respectively (right).of nerve fascicles from uninjured Timing of reconstruction Restoration of elbow flexion cannerves. This nerve re-routing Just as important for optimal significantly improve the activitiesessentially converts a proximal functional outcome is timing to of daily living for the patient.nerve injury into a distal nerve surgery. Studies have shown that Restoration of shoulderinjury closer to the motor endplate. nerve transfers performed within stabilization and abduction is theBy shifting the injury closer to the 6 months post-trauma yield results second most important prioritytarget muscle, regeneration of the superior to transfers performed in primary reconstruction of highproximal nerve stump can reach the after 6 months post-trauma.11 It brachial plexus injuries.9-10 Themotor endplate before degradation. is important to have the patient axillary and suprascapular nervesThis is the essence of nerve transfer. evaluated by a neurologist and may also be compromised in The three important criteria upper extremity surgeon as soon C5-C6 injuries. The axillary andfor primary brachial plexus as possible following trauma. suprascapular nerves innervatereconstruction are patient selection, the deltoid and the suprascapulartiming to reconstruction, and Restoration of Function muscles, respectively. Theseprioritizing the restoration of function. muscles abduct and stabilize When contemplating brachial the shoulder, providing a solid plexus reconstruction, one mustPatient selection platform for hand function. have a specific plan since each Multiple studies have shown patient’s injury pattern is inherentlythat younger patients recover from different. The two most important Nerve transfer options fornerve transfer faster and ultimately actions which need to be restored C5-C6 brachial plexus injurieshave a better outcome. Typically in the high plexus injury are elbow The current nerve transfer usedpatients under 40 years of age flexion and shoulder abduction.9 for the restoration of elbow flexionhave the best functional outcome Elbow flexion is critical to human is the Oberlin transfer which wasfollowing nerve transfer.10 interaction with the environment and first described by Christophe Oberlin Tobacco use and compliance its restoration is the principal goal of Paris in 1994. He described theshould also be considered. It is of brachial plexus reconstruction. transfer of a single redundantcritical that the patient adheres to an This is particularly true in C5-C6 fascicle from the ulnar nerveoccupational therapy and physical injuries where the musculocutaneous directly coapted to the biceps motortherapy program before surgery. nerve has been compromised. fascicle.12 This transfer restoresEven if function is restored, if the The musculocutaneous nerve elbow flexion following loss of thejoints have ceased working then innervates the brachialis and musculocutaneous nerve, a branch ofthe reconstruction is for naught. biceps which are the elbow flexors. the lateral cord. In 2004 he reported January/February 2010 | Vol. 106 1
  5. 5. Scientific Article | that 20 of 32 patients who underwent brachialis, a strong elbow flexor, description was through an anterior the procedure recovered active has improved outcome following approach which was a difficult motion against gravity and resistance loss of the musculocutaneous dissection for the surgeon, not (M4).12 This procedure was validated nerve. In 2005 Oberlin reported well tolerated by the patient, and by Leechavengvongs in Thailand 15 of 15 patients recovered M4 required an interpositional graft. The who reported his experience with strength and MacKinnon reported transfer was essentially abandoned 26 of 32 patients who had regained 6 of 6 recovering M4 strength.14,15 for other options until 2003 when M4 elbow flexion following the No patients from either study Leechavengvongs from Thailand Oberlin transfer.13 In both studies exhibited motor or sensory loss described the posterior approach.18 none of the patients displayed any from the donor nerves. The addition Through a single longitudinal sequelae from sacrificing an ulnar of the median nerve coaptation incision the anterior branch to the nerve fascicle as a donor.12,13 has increased the success of the axillary nerve is isolated in the Unfortunately some patients in procedure without sacrificing quadrilateral space. Subsequently the French and Thai studies required native residual hand function.14,15 the radial nerve is dissected in the further muscle origin transfers Two nerve transfers, the radial to triangular interval just distal to the (Steindler Flexorplasty) to improve axillary and spinal accessory to the teres major. At this point the motor elbow flexion. Researchers found suprascapular, are currently used nerve to the long head of the triceps is that when the brachialis muscle was to restore shoulder stabilization and identified and coapted to the anterior re-innervated the patient achieved abduction in upper plexus avulsions. branch of the axillary nerve restoring better elbow flexion than biceps re- These transfers can be used innervation to the deltoid muscle. innervation alone.12-15 In search of a independently, but they have been The posterior approach was procedure which would eliminate the shown to provide better results when revolutionary because the ease of need for additional muscle transfer, performed in combination.16,17 Good dissection, no interpositional graft Oberlin along with Susan MacKinnon outcome ( M3) has been reported was required, and it places the in St. Louis, described the Oberlin in 86% of patient undergoing donor close to the motor endplate double nerve transfer in 2003.14,15 In concurrent transfer to both the of the recipient.18 Additionally this repair one redundant fascicle axillary and suprascapular nerve.16,17 the nerve transfer can improve from the ulnar and median nerves are Transferring the radial to axillary shoulder stability and abduction coapted directly to the motor braches nerve was originally described because it is additive with the of the biceps and brachialis muscles. in 1948 by Alexander Lurje from spinal accessory to suprascapular The additional re-innervation of the Russia.5 However his initial nerve transfer. Leechavengvongs Figure 6. Cadaveric dissection showing the spatial relationship between the radial nerve in the triangular space and the axillary nerve in the quadrilateral space. 1 West Virginia Medical Journal
  6. 6. | Scientific ArticleFigure 7. brachial plexus. Annals of Surgery. 1948 Feb.;127(2):317-26.Summary of nerve injuries, transfer options, and restored functions for the upper plexus. 6. Seddon HJ: Three types of nerve injury. Nerve Transfer options Brain. 1943 Dec.;66(4):237–88. 7. Sunderland S. A classification of peripheral Injured Nerve Nerve Transfer function restored nerve injuries producing loss of function. Musculocutaneous Median and ulnar fascicles Elbow flexion 8. Brain. 1951 Dec.;74(4):491-516. Terzis JK, Kostopoulos VK. The surgical Axillary  Radial fascicles  Shoulder stability and abduction treatment of brachial plexus injuries in Suprascapular  Spinal accessory (XI) fascicles  Shoulder stability and abduction adults. Plast Reconstr Surg. 2007 Apr.;119(4):73-92. 9. Weber R, MacKinnon S. Nerve transfers in the upper extremity. Journal of thereported that 7 of 7 patients achieved reported 13 of 15 patients with American Society for Surgery of the Hand.deltoid function against gravity complete C5-C6 avulsion regained 10. 2004 Aug.;4(3):200-13. Dvali L, Mackinnon S. Nerve repair,(M4) with a mean of 124 degrees M4 elbow and shoulder abduction.16 grafting, and nerve transfers. Clin Plastof shoulder abduction.19 There was This series used the older single Surg. 2003 Apr.;30(2):203-21. Oberlin transfer and more recent 11. Terzis JK, Kostas I. Suprascapular nerveno reported shoulder subluxation reconstruction in 118 cases of adultor loss of triceps function.19 experience suggests that elbow posttraumatic brachial plexus. Plast The spinal accessory to flexion can be further improved. Reconstr Surg. 2006 Feb.;117(2):613-29.suprascapular nerve transfer is 12. Teboul F, Oberlin C. Transfer of fascicles from the ulnar nerve to the nerve to thean older yet reliable option for Conclusion biceps in the treatment of upper brachialrestoration of glenohumeral stability Injury to the brachial plexus is a plexus palsy. J Bone Joint Surg Am. 2004and shoulder abduction.8,11,20 The devastating and life altering event for July;86(7):1485-90. 13. Leechavengvongs S, Witoonchart K, et. al.spinal accessory nerve is a cranial the patient as well as a challenging Nerve transfer to biceps muscle using anerve which serves to innervate reconstructive dilemma for the part of the ulnar nerve in brachial plexusthe trapezius muscle distal in its surgeon. Recent strides have been injury (upper arm type): a report of 32 cases. J Hand Surg Am. 1998course. Originally this transfer made in the diagnosis, management, July;23(4):711-6.required a large supraclavicular and treatment of upper brachial 14. Liverneaux PA, Oberlin C, et. al.Millesi incision for access however plexus root avulsion. Nerve transfers Preliminary results of double nerve transfer to restore elbow flexion in upper typerecent advances in technique have have evolved into a valuable option; brachial plexus palsies. Plast Reconstrpermitted much smaller and more however, a thorough understanding Surg. 2006 Mar.;117(3):915-9.aesthetic incisions. This transfer of clinical anatomy and timing to 15. Mackinnon SE, Novak CB, et. al. Results of reinnervation of the biceps andhas been successful largely due to coaptation are crucial for optimal brachialis muscles with a double fascicularits consistent anatomy, and close outcome. A combined three nerve transfer for elbow flexion. J Hand Surg Am.proximity to the donor nerve which transfer consisting of the Double 2005 Sep.;30(5):978-85. 16. Leechavengvongs S, Witoonchart K, et. al.negates the need for interpositional Oberlin, radial to the axillary, Combined nerve transfers for C5 and C6grafting. Terzis reported that in 118 and the spinal accessory to the brachial plexus avulsion injury. J Handspinal accessory transfers outcomes suprascapular has been shown to be Surg Am. 2006 Feb.;31(2):183-9. 17. Bertelli JA, Ghizoni MF. Reconstruction ofwere good to excellent in 79% of an effective primary reconstruction C5 and C6 brachial plexus avulsion injurypatients.11 These results were echoed for adult C5-C6 injuries. by multiple nerve transfers: spinalby Spinner who reported a good accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateraloutcome in 74% of his 577 transfers.21 References head branch to axillary nerve. J Hand Surg When considering brachial 1. Aydn A, et. al. Three-thousand-year-old Am. 2004 Jan.;29(1):131-9.plexus reconstruction for C5-C6 written reference to a description of what 18. Witoonchart K, Leechavengvongs S, et. al. Nerve transfer to deltoid muscle using theroot avulsions these three nerve might be the earliest brachial plexus nerve to the long head of the triceps, part I: injuries in the Iliad of Homer. Plasttransfers have been shown to be Reconstr Surg. 2004 Oct.;114(5):1352-3. an anatomic feasibility study. J Hand Surgeffective both individually and in 2. da Vinci, Leonardo. The brachial plexus. Am. 2003 July;28(4):628-32. 19. Leechavengvongs S, Witoonchart K, et. al.combination. This “bundled” transfer c.1508. The Royal Collection. © 2005, Her Majesty Queen Elizabeth II. Available Nerve transfer to deltoid muscle using thewhen performed prior to six months online: http://www.universalleonardo.org/ nerve to the long head of the triceps, partfollowing injury in patients under 40 work.php?id =355. August 5, 2008. II: a report of 7 cases. J Hand Surg Am.years of age has achieved excellent 3. Kennedy, Robert. On the restoration of co- 2003 July;28(4):633-8. ordinated movements after nerve-crossing, 20. Malessy MJ, et. al. Evaluation ofresults.16,17 The bundle is successful with interchange of function of the cerebral suprascapular nerve neurotization afterbecause it concentrates on two critical cortical centers. Philosophical Transactions nerve graft or transfer in the treatment ofareas, elbow flexion and shoulder of the Royal Society of London, Series B, brachial plexus traction lesions. Containing Papers of a Biologicalstability. Additionally it provides Character. 1901;194:127-162. Neurosurgical Focus. 2004similar motor to motor nerve 4. Langley JN, Anderson HK. The union of Sep.;101(3):377-89. different kinds of nerve fibres. J. Physiol. 21. Songcharoen P, Spinner R., et. al. Brachialcoaptation without interpositional plexus injuries in the adult. Nerve 1904 Aug.;31(5):365-91.grafts which speeds re-education. 5. Lurje A. Concerning surgical treatment of transfers: the Siriraj Hospital experience.A recent study from Thailand traumatic injury of the upper division of the Hand Clin. 2005 Feb.;21(1):83-9. January/February 2010 | Vol. 106 17

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