Long Thoracic Nerve Transfer for Children With Brachial Plexus Injuries.

INTRODUCTION: The transfer of intraplexal and extraplexal nerves for restoration of function in children with traumatic and birth brachial plexus palsies has become well accepted. Little has been written about using the long thoracic nerve (LTN) as a donor in reanimation of the upper extremity. The authors present a case series of nerve transfers using the LTN as a donor in brachial plexus injury. METHODS: A retrospective chart review was performed over a 10-year period at a single institution. The primary outcome measure was the active movement scale. RESULTS: Fourteen patients were included in the study: 10 birth injury patients and 4 blunt trauma patients. Average follow-up time was 21.3 and 10.75 months, respectively. The best outcomes were seen when the LTN was used for reinnervation of the obturator nerve in free functioning muscle transfers. The next most successful recipients were the musculocutaneous and axillary nerves. Outcomes were poor in transfers to the posterior interosseous fascicles of the radial nerve and the radial nerve branches to the triceps. DISCUSSION: The LTN may be a potential nerve donor for musculocutaneous or axillary nerve reinnervation in patients with brachial plexus injuries when other donors are not available during a primary plexus reconstruction. However, the best use may be for delayed neurotization of a free functioning muscle transfer after the initial plexus reconstruction has failed and no other donors are available. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Painful Myoclonus Triggered by Lateral Antebrachial Cutaneous Nerve Entrapment at the Brachioradialis Muscle.

Compression of the lateral antebrachial cutaneous nerve is a rare clinical entrapment syndrome often overlooked as an initial etiology of pain. We present a case of an episodic upper limb painful movement disorder (myoclonus) in a 16-yr-old adolescent girl with a remote history of a surgically stabilized supracondylar humeral fracture who was later found to have entrapment of the lateral antebrachial cutaneous nerve. The incidence of a painful myoclonus triggered by a peripheral nerve entrapment is unknown. Combining a history and physical examination, electromyography, nerve conduction studies, and ultrasound enabled us to make an accurate diagnosis that was confirmed by resolution of symptoms after surgical release. This study conforms to all CARE guidelines and reports the required information accordingly (see Supplemental Check list, Supplemental Digital Content 1, http://links.lww.com/PHM/A855).

Nerve transfers for peripheral nerve injury in the upper limb: a case-based review.

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

Neurologic complications of shoulder joint replacement.

BACKGROUND: Little attention has been given to neurologic complications after shoulder joint replacement (SJR). Previously thought to occur infrequently, it is likely that many are not clinically recognized, and they can result in postoperative morbidity and impair the patient's recovery. The purpose of this study was to document the prevalence of nerve complications after SJR, to identify the nerves involved, and to define patient outcomes. METHODS: This was a retrospective review of 211 SJRs in 202 patients during a 5-year period were included, with 89 male and 122 female patients at an average age of 70 years. All patients underwent a comprehensive analysis of any postoperative nerve complication, including onset, duration, investigation, treatment, and symptom resolution. RESULTS: Of the 211 SJR procedures, 44 were identified as having sustained a nerve complication (20.9%), with 36 female (81.8%) and 8 male patients (18.2%). Reverse SJR was associated with the highest number of nerve complications. The median nerve (25 patients) and musculocutaneous nerve (8 patients) were most commonly involved. Most nerve complications were transient and resolved within 6 months. Permanent sequelae and injuries that required secondary surgical intervention were rare. CONCLUSION: The occurrence of nerve complications after SJR is common, but almost all will fully recover. Most are transient neurapraxias involving the lateral cord of the brachial plexus. Women are more likely to be affected, as are patients who have undergone prior surgery to the affected shoulder. Most are likely to be the result of excessive traction or direct injury to the nerves during glenoid exposure.

Novel Atraumatic End-to-Side Repair Model Exhibits Robust Collateral Sprouting Independent of Donor Fiber Injury.

BACKGROUND: A central issue underlying end-to-side neurorrhaphy technique is whether injury to the donor nerve fibers is necessary for successful reinnervation of the recipient nerve. To address this question, the authors developed a novel atraumatic end-to-side neurorrhaphy model that uses the preexisting anatomical structure of the median nerve as the Y-chamber to study the mechanism of collateral sprouting. METHODS: In this rat forelimb model, the authors transected the musculocutaneous nerve and the lateral head of the median nerve, and coapted their distal stumps together. In this model, the authors use the medial head of the median nerve as the donor nerve, and the lateral head of the median nerve (distal stump) as a Y-shaped chamber, which provided structural connection to the recipient musculocutaneous nerve in end-to-side fashion. RESULTS: Three months after surgery, converging histologic, electrophysiologic, and behavioral observations confirmed the successful reinnervation of the recipient nerve. Retrograde labeling indicated that sensory fibers exhibited greater collateral sprouting than observed for motor fibers. Interestingly, fluorescence of these collateral sprouting fibers was present only when the median nerve lateral head was attached to the musculocutaneous nerve of the biceps, indicating that factors derived from the denervated tissue likely induced the collateral sprouting in this model. CONCLUSIONS: The authors' findings provide strong evidence that collateral sprouting can be robustly initiated independent of donor nerve fiber injury. The authors' model can accelerate the understanding of the mechanism underlying end-to-side neurorrhaphy and the optimization of its clinical use.

Management of Isolated Musculocutaneous Injury: Comparing Double Fascicular Nerve Transfer With Conventional Nerve Grafting.

PURPOSE: To compare the functional outcomes of nerve grafts and nerve transfers in the management of isolated musculocutaneous nerve (MCN) injuries. METHODS: We performed a retrospective case-control study of isolated MCN injury managed at a tertiary care center. The study group was composed of 12 patients managed with double nerve transfer whereas the 8 patients in the grafted group constituted the control group. RESULTS: In the study group, stab and missile injuries constituted most cases with a denervation period ranging between 3 and 9 months. Eleven patients in this group experienced a full range of active elbow flexion whereas one had antigravity flexion of 120°. Electromyography revealed the first sign of reinnervation of biceps at 10 ± 2 weeks, compared with 20 ± 2 weeks in the grafted group. The overall trend was for patients in the study group to have earlier return of active elbow flexion and better restoration of elbow flexion strength and range of (presumably active) elbow motion than those treated with grafting, although none of these measures reached statistical significance. CONCLUSIONS: We found that distal nerve transfer was a superior method of managing isolated MCN injury compared with conventional nerve grafting.

Musculocutaneous nerve injury in a high school pitcher.

: Nontraumatic musculocutaneous nerve palsy is a rare injury that can occur in throwers. We present a case of musculocutaneous nerve injury in a high school pitcher, which has rarely been previously reported. The unique electromyography findings add to the overall spectrum seen with musculocutaneous nerve injuries in throwers. Sensory abnormalities may not be present at initial evaluation, but rather weakness or pain of the biceps is the most common presenting concern. Electrodiagnostic evaluation is paramount for confirmation of diagnosis, yet the timing of this study is critical for its accuracy. Rest and progressive physical therapy remain as the current treatment of choice. Resolution of symptoms, although time consuming, is complete in the majority of cases, including ours.

End-to-side neurorrhaphy in brachial plexus reconstruction.

OBJECT: Although a number of theoretical and experimental studies dealing with end-to-side neurorrhaphy (ETSN) have been published to date, there is still a considerable lack of clinical trials investigating this technique. Here, the authors describe their experience with ETSN in axillary and musculocutaneous nerve reconstruction in patients with brachial plexus palsy. METHODS: From 1999 to 2007, out of 791 reconstructed nerves in 441 patients treated for brachial plexus injury, the authors performed 21 axillary and 2 musculocutaneous nerve sutures onto the median, ulnar, or radial nerves. This technique was only performed in patients whose donor nerves, such as the thoracodorsal and medial pectoral nerves, which the authors generally use for repair of axillary and musculocutaneous nerves, respectively, were not available. In all patients, a perineurial suture was carried out after the creation of a perineurial window. RESULTS: The overall success rate of the ETSN was 43.5%. Reinnervation of the deltoid muscle with axillary nerve suture was successful in 47.6% of the patients, but reinnervation of the biceps muscle was unsuccessful in the 2 patients undergoing musculocutaneous nerve repair. CONCLUSIONS: The authors conclude that ETSN should be performed in axillary nerve reconstruction but only when commonly used donor nerves are not available.

Subbrachial approach to humeral shaft fractures: new surgical technique and retrospective case series study.

BACKGROUND: There are few surgical approaches for treating humeral shaft fractures. Here we present our results using a subbrachial approach. METHODS: We conducted a retrospective case series involving patients who had surgery for a humeral shaft fracture between January 1994 and January 2008. We divided patients into 4 groups based on the surgical approach (anterior, anterolateral, posterior, subbrachial). In all patients, an AO 4.5 mm dynamic compression plate was used. RESULTS: During our study period, 280 patients aged 30-36 years underwent surgery for a humeral shaft fracture. The average duration of surgery was shortest using the subbrachial approach (40 min). The average loss of muscle strength was 40% for the anterolateral, 48% for the posterior, 42% for the anterior and 20% for the subbrachial approaches. The average loss of tension in the brachialis muscle after 4 months was 61% for the anterolateral, 48% for the anterior and 11% for the subbrachial approaches. Sixteen patients in the anterolateral and anterior groups and 6 patients in the posterior group experienced intraoperative lesions of the radial nerve. No postoperative complications were observed in the subbrachial group. CONCLUSION: The subbrachial approach is practical and effective. The average duration of the surgery is shortened by half, loss of the muscle strength is minimal, and patients can resume everyday activities within 4 months. No patients in the subbrachial group experienced injuries to the radial or musculocutaneous nerves.

Electrodiagnosis of brachial plexopathies and proximal upper extremity neuropathies.

This article describes the normal anatomy of the brachial plexus and its major terminal branches, as well as the major causes and clinical presentations of lesions of these structures. An approach to electrodiagnosis of brachial plexopathies and proximal upper extremity neuropathies is provided, with an emphasis on those nerve conduction studies and portions of the needle examination, which permit localization of lesions to specific trunks, cords, and terminal branches. The importance of specific sensory nerve conduction studies for differentiating plexopathies from radiculopathies and mononeuropathies is emphasized.

Musculocutaneous neuropathy after anaesthesia for thyroid surgery: a case report.

Postoperative isolated injury of the musculocutaneous nerve is a rare disorder and complication. Reported cases are claimed to present with loss of biceps and brachialis power without neuropathic pain. When injury occurs to one of the terminal branches of the brachial plexus, the lateral cutaneous nerve of the forearm, pain is the major symptom and it typically radiates along the radial aspect of the forearm. In the literature, isolated lesions of the musculocutaneous nerve have been attributed to repeated microtrauma, indirect trauma or direct trauma to the nerve. It may also occur due to strenuous extension of the forearm for prolonged periods.

Morphological assessment of early axonal regeneration in end-to-side nerve coaptation models.

Histological changes were observed in peripheral nerves following end-to-side nerve coaptation to determine the effects of perineurial opening and deliberate donor nerve injury during surgery. Twenty rats were randomised into four groups as follows: group 1, end-to-side nerve coaptation without perineurial opening; group 2, end-to-side nerve coaptation with simple perineurial opening; group 3, end-to-side nerve coaptation with partial crush injury after perineurial opening; group 4, end-to-side nerve coaptation with partial neurotomy after perineurial opening. Seven days after coaptation of the musculocutaneous (recipient) nerve to the ulnar (donor) nerve, the nerves were immunohistochemically analysed using antibodies against neurofilament-H (RT97) and phosphorylated GAP-43 (p-GAP-43). The former labels all axons, including regenerating axons and degenerated axonal debris, while the latter only labels regenerating axons. Results demonstrated no regenerating nerves in the recipient nerve of group 1. In group 2, because nerve herniation from the perineurial opening partially injured donor nerve fibres, some regenerating axons extended proximally and distally along the partially injured fibres in the donor nerve; some of these regenerating axons also extended into the recipient nerve via the perineurial opening. In groups 3 and 4, thin regenerating axons were more prominent in recipient and donor nerves compared with group 2. Statistical evaluation revealed increased efficacy of perineurial opening and deliberate donor nerve injury in end-to-side nerve coaptation, suggesting that partial nerve fibre herniation with partial axonotmesis or neurotomesis was important for effective axonal regeneration in end-to-side nerve coaptation.

Injuries of the terminal branches of the infraclavicular brachial plexus: patterns of injury, management and outcome.

We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves.

Ciliary neurotrophic factor promotes motor reinnervation of the musculocutaneous nerve in an experimental model of end-to-side neurorrhaphy.

BACKGROUND: It is difficult to repair nerve if proximal stump is unavailable or autogenous nerve grafts are insufficient for reconstructing extensive nerve damage. Therefore, alternative methods have been developed, including lateral anastomosis based on axons' ability to send out collateral sprouts into denervated nerve. The different capacity of a sensory or motor axon to send a sprout is controversial and may be controlled by cytokines and/or neurotrophic factors like ciliary neurotrophic factor (CNTF). The aim of the present study was to quantitatively assess collateral sprouts sent out by intact motor and sensory axons in the end-to-side neurorrhaphy model following intrathecal administration of CNTF in comparison with phosphate buffered saline (vehiculum) and Cerebrolysin. The distal stump of rat transected musculocutaneous nerve (MCN) was attached in an end-to-side fashion with ulnar nerve. CNTF, Cerebrolysin and vehiculum were administered intrathecally for 2 weeks, and all animals were allowed to survive for 2 months from operation. Numbers of spinal motor and dorsal root ganglia neurons were estimated following their retrograde labeling by Fluoro-Ruby and Fluoro-Emerald applied to ulnar and musculocutaneous nerve, respectively. Reinnervation of biceps brachii muscles was assessed by electromyography, behavioral test, and diameter and myelin sheath thickness of regenerated axons. RESULTS: Vehiculum or Cerebrolysin administration resulted in significantly higher numbers of myelinated axons regenerated into the MCN stumps compared with CNTF treatment. By contrast, the mean diameter of the myelinated axons and their myelin sheath thickness in the cases of Cerebrolysin- or CNTF-treated animals were larger than were those for rats treated with vehiculum. CNTF treatment significantly increased the percentage of motoneurons contributing to reinnervation of the MCN stumps (to 17.1%) when compared with vehiculum or Cerebrolysin treatments (at 9.9 or 9.6%, respectively). Reduced numbers of myelinated axons and simultaneously increased numbers of motoneurons contributing to reinnervation of the MCN improved functional reinnervation of the biceps brachii muscle after CNTF treatment. CONCLUSION: The present experimental study confirms end-to-side neurorrhaphy as an alternative method for reconstructing severed peripheral nerves. CNTF promotes motor reinnervation of the MCN stump after its end-to-side neurorrhaphy with ulnar nerve and improves functional recovery of the biceps brachii muscle.