Brachial plexus injury management

1. Contralateral C7 Transfer
Dr. Satish Kumar.S
MCh Plastic Surgery
Final Year Resident

2. Introduction
• Opposite side unaffected C7 brachial plexus nerve root is used to
neurotize the nerves on the affected side by different routes and nerve
grafts to achieve function on the affected side without compromising
function in the normal side.

3. History
• Shanghai Huashan Hospital in 1986 by Dr. Gu et al.

4. Indications
• No available nerves in affected side
• In total root avulsion, in addition to available nerves on affected site
• When any neurotization fails

5. Why C7?
• C7 innervated muscles are cross – innervated by C6, C8 roots
• No significant loss of any muscle function

6. Decisions
• Patient selection
• Staged procedure
• Single stage procedure
• Which part of C7 to use
• Which recipient nerve

7. Patient selection
• Need of surgery in normal side
• Effects of the surgery on the normal side
• Need for second stage
• Time delay for positive effects
• Stress on strict PT and ES follow-up by pt

8. Staged procedure

10. Vascularised Ulnar Nerve Graft
• I/L ulnar nerve used as a pedicled graft
• Based on Superior Ulnar Collateral artery (SUCA)
• SUCA
• - brachial artery – mid humeral level
• 14-22 cm proximal to ME
• Pierces IM septum
• Posterior compartment > ulnar nerve
• Accompanies nerve 4-15 cm
• 3 arteria nervorum
• Deep to FCU anastomosis – PURA & IUCA

15. Disadvantages
• Sacrifice of ulnar nerve
• Time delay of stages
• Delay in growth of nerve (longer route)

16. Single stage
• Direct co-aptation of CC7 to recipient nerve
• Single procedure
• Different routes

17. C.S. of neck

22. Other routes
• Trans discal route
• Trans carotid sheath route

23. Disadvantages
• Extensive dissection of brachial plexus and normal neck anatomy
• Shortening of humerus might be needed

24. Which part of C7 to use?
• Complete C7 root – size mismatch
• Anterior part - sensory
• Posterior part - motor

25. Recipient nerve
• Anterior div. Lower trunk – Wrist/Finger flexion
• Posterior div. Lower trunk – Wrist/Finger extension
• Median nerve
• Radial nerve
• MCN

26. Steps of Surgery – Stage I
• Dissection of opposite side brachial plexus
• Harvesting Vascularised Ulnar nerve Graft
• Coaptation of VUNG to CC7 root

27. Delay for Stage II
• Growth of nerve fascicles from CC7 into VUNG
• Progress of Tinnel’s from CC7 root along path of
VUNG upto axilla
• 10-14 months

28. Steps of Surgery – Stage II
• Division of loop of VUNG
• Division of Recipient nerve
• Coaptation of divided end of VUNG to recipient nerve

29. Incision

30. Follow up
• After stage I
• 3 weeks immobilization
• Shoulder adduction, elbow extension exercise
• Improve nerve growth
• After stage II
• 10-12 months for 1st movement to be noticed
• Initiation of movement by healthy limb
• Reinnervated muscles activated by adducting, internally rotating, extending
C/L shoulder and extending C/L elbow

31. Complications
• Temporary motor deficit
• Shoulder extension, adduction, elbow extension, forearm pronation,
wrist extension, hand movement
• Temporary sensation loss in IF, MF
• Full recovery – 6 months

32. THANK YOU