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

Armed Forces Medical College and Command Hospital, Pune, India.
The Journal of hand surgery (Impact Factor: 1.67). 12/2011; 36(12):2002-9. DOI: 10.1016/j.jhsa.2011.08.017
Source: PubMed


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.
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.
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.
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.

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    • "Sparing of 1 or 2 fascicle from the ulnar and median nerves does not result in any subjective deficit of hand function. We have found that there is no added advantage in fascicular selection using a nerve stimulator, while performing the Oberlinnerve transfers.[18] "
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    ABSTRACT: Management of brachial plexus injury is a demanding field of hand and upper extremity surgery. With currently available microsurgical techniques, functional gains are rewarding in upper plexus injuries. However, treatment options in the management of flail and anaesthetic limb are still evolving. Last three decades have witnessed significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in the diagnostic modalities, incorporation of intra-operative nerve stimulation techniques, more liberal use of nerve grafts in bridging nerve gaps, and the addition of new nerve transfers, which selectively neurotise the target muscles close to the motor end plates. Newer research works on the use of nerve allografts and immune modulators (FK 506) are under evaluation in further improving the results in nerve reconstruction. Direct reimplantation of avulsed spinal nerve roots into the spinal cord is another area of research in brachial plexus reconstruction.
    No preview · Article · May 2014 · Indian Journal of Plastic Surgery
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    ABSTRACT: Background Traumatic brachial plexus injury is a devastating condition resulting mainly from motor cycle accidents and primarily affecting the young adults. In the past there was a pessimistic attitude in the management of these injuries. However in last two decades with the introduction of microsurgical techniques and advances in imaging modalities, these injuries are being explored and repaired early with satisfactory to good functional out comes.Methods Neurolysis, nerve repair, nerve grafting, nerve transfer, pedicle muscle transfer and functioning free-muscle transfer are the main surgical procedures in the management of brachial plexus injury. In the management of these injuries an immediate intervention is considered in penetrating trauma. All other common high velocity traction injuries are initially observed for a spontaneous recovery. If there are no signs of recovery by three months, surgery is indicated, as further delay will affect the ultimate results. In global brachial plexus palsy with all root avulsions, intervention is even earlier, as chances of spontaneous recovery are practically nil.ResultsGood results are expected with early intervention in upper plexal lesions. Results are favorable with short nerve grafts, distal nerve transfers, and intraplexal neurotization. The aim in global brachial plexus palsy is to restore the elbow flexion and provide a stable shoulder. Restoration of a fully functional and sensate hand is still far from being a reality.Conclusion The management of brachial plexus injury remains a challenging problem. Functional results have considerably improved in the past two decades with the incorporation of microsurgical techniques in nerve surgery, and advancements in anesthesia. Following microsurgical reconstruction many of these patients are expected to return to their original work and amputation is no longer considered a treatment option.
    No preview · Article · Jun 2012
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    ABSTRACT: BACKGROUND:: Nerve transfers or graft repairs in upper brachial plexus palsies are two available options for elbow flexion recovery. OBJECTIVE:: To assess outcomes of biceps muscle strength when treated either by grafts or nerve transfer. METHODS:: A standard supraclavicular approach was performed in all patients. When roots were available, grafts were employed directed to proximal targets. Otherwise, a distal ulnar nerve fascicle was transferred to the biceps branch. Elbow flexion strength was measured with a dynamometer, and an index comparing the healthy arm and the operated-upon side was developed. Statistical analysis to compare both techniques was performed. RESULTS:: Thirty-five patients (34 males) were included in this series. Mean age was 28.7 years (SD =8.7). Twenty-two cases (62.8%) presented with a C5-C6 injury, while 13 cases (37.2%) had a C5-C6-C7 lesion. Seventeen patients received reconstruction with grafts and 18 cases were treated with a nerve transfer from the ulnar nerve to the biceps. The trauma to surgery interval (mean 7.6 months in both groups), strength in the healthy arm, and follow-up duration were not statistically different. On the BMRC muscle strength scale, 8 of 17 (47%) patients with a graft achieved ≥ M3 biceps flexion postoperatively, versus 16 of 18 (88%) post nerve transfers (p = .024). This difference persisted when a muscle strength index assessing improvement relative to the healthy limb was used (p = .031). CONCLUSION:: The results obtained from ulnar nerve fascicle transfer to the biceps branch were superior to those achieved through reconstruction with grafts.
    No preview · Article · Jul 2012 · Neurosurgery
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