Evaluation of nerve transfer options for treating total brachial plexus avulsion injury: A retrospective study of 73 participants

Kai-Ming Gao, Jing-Jing Hu, Jie Lao, Xin Zhao, Kai-Ming Gao, Jing-Jing Hu, Jie Lao, Xin Zhao

Abstract

Despite recent great progress in diagnosis and microsurgical repair, the prognosis in total brachial plexus-avulsion injury remains unfavorable. Insufficient number of donors and unreasonable use of donor nerves might be key factors. To identify an optimal treatment strategy for this condition, we conducted a retrospective review. Seventy-three patients with total brachial plexus avulsion injury were followed up for an average of 7.3 years. Our analysis demonstrated no significant difference in elbow-flexion recovery between phrenic nerve-transfer (25 cases), phrenic nerve-graft (19 cases), intercostal nerve (17 cases), or contralateral C7-transfer (12 cases) groups. Restoration of shoulder function was attempted through anterior accessory nerve (27 cases), posterior accessory nerve (10 cases), intercostal nerve (5 cases), or accessory + intercostal nerve transfer (31 cases). Accessory nerve + intercostal nerve transfer was the most effective method. A significantly greater amount of elbow extension was observed in patients with intercostal nerve transfer (25 cases) than in those with contralateral C7 transfer (10 cases). Recovery of median nerve function was noticeably better for those who received entire contralateral C7 transfer (33 cases) than for those who received partial contralateral C7 transfer (40 cases). Wrist and finger extension were reconstructed by intercostal nerve transfer (31 cases). Overall, the recommended surgical treatment for total brachial plexus-avulsion injury is phrenic nerve transfer for elbow flexion, accessory nerve + intercostal nerve transfer for shoulder function, intercostal nerves transfer for elbow extension, entire contralateral C7 transfer for median nerve function, and intercostal nerve transfer for finger extension. The trial was registered at ClinicalTrials.gov (identifier: NCT03166033).

Keywords: accessary nerve; brachial plexus-avulsion injury; contralateral C7 nerve; elbow function; intercostal nerve; median nerve; nerve regeneration; nerve transfer; neural regeneration; phrenic nerve; radial nerve; shoulder function.

Conflict of interest statement

None declared

Figures

Figure 1
Figure 1
Trial flow chart.
Figure 2
Figure 2
A patient under general anesthesia in the lateral position (A) and the skin incision superior to the scapular spine (B). The trapezius and the supraspinatus muscle were retracted and then the spinal accessory nerve (♦) was coapted to the suprascapular nerve (#) with no tension.
Figure 3
Figure 3
Preparation of the pedicled ulnar nerve graft. (A) The ulnar nerve (↑) of the affected upper limb was transected at the wrist level and the full-length nerve pedicled by the superior ulnar collateral artery (↓) was harvested. (B) The measurement of the ulnar nerve (↑) to the contralateral neck.
Figure 4
Figure 4
Intercostal nerve harvesting. (A) Two intercostal nerves (*) and the long head of the triceps branch (▲) were harvested. (B) Two intercostal nerves (*) were directly coapt-ed to the long head of the triceps branch (▲) with no tension in the axilla with the arm in full abduction.

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