A novel strategy for repairing preganglionic cervical root avulsion in brachial plexus injury by sural nerve grafting

Clinical article

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Object

In this study, the authors evaluated the efficacy of a new surgical strategy for reconnecting the injured brachial plexus with the spinal cord using fibrin glue containing acidic fibroblast growth factor as an adhesive and neurotrophic agent.

Methods

Eighteen patients with preganglionic brachial plexus injuries, each with varying degrees of upper limb dysfunction, underwent cervical laminectomy with or without sural nerve grafting. The treatment of each avulsed root varied according to the severity of the injury. Some patients also underwent a second-stage operation involving supraclavicular brachial plexus exploration for reconnection with the corresponding segment of cervical spinal cord at the trunk level. Muscle strength was graded both pre- and postoperatively with the British Medical Research Council scale, and the results were analyzed with the Friedman and Wilcoxon signed-rank tests.

Results

Muscle strength improvements were observed in 16 of the 18 patients after 24 months of follow-up. Significant improvements in mean muscle strength were observed in patients from all repair method groups at 12 and 24 months postoperatively (p < 0.05). Statistical significance was not reached in the groups with insufficient numbers of cases.

Conclusions

The authors' new surgical strategy yielded clinical improvement in muscle strength after preganglionic brachial plexus injury, such that nerve regeneration may have taken place. Reconnection of the brachial plexus to the cervical spinal cord is possible. Functional motor recovery, observed through increases in Medical Research Council–rated muscle strength in the affected arm, is likewise possible.

Abbreviations used in this paper: aFGF = acidic fibroblast growth factor; BPI = brachial plexus injury; EMG = electromyography; LIMOC = lateral interscalenic, multilevel, oblique corpectomy; MRC = Medical Research Council; NCS = nerve conduction studies; SCI = spinal cord injury.
Article Information

Contributor Notes

Address correspondence to: Henrich Cheng, M.D., Ph.D., Neural Regeneration Laboratory, Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Room 509, 17F, No. 201, Shih-Pai Road, Sec. 2 Peitou, Taipei 11217, Taiwan. email: hc_cheng@vghtpe.gov.tw.Please include this information when citing this paper: published online January 2, 2009; DOI: 10.3171/2008.8.JNS08328.
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References
  • 1

    Bertelli JAGhizoni MF: Brachial plexus avulsion injury repairs with nerve transfers and nerve grafts directly implanted into the spinal cord yield partial recovery of shoulder and elbow movements. Neurosurgery 52:138513902003

    • Search Google Scholar
    • Export Citation
  • 2

    Bertelli JAGhizoni MF: Concepts of nerve regeneration and repair applied to brachial plexus reconstruction. Microsurgery 26:2302442006

    • Search Google Scholar
    • Export Citation
  • 3

    Carlstedt TP: Spinal nerve root injuries in brachial plexus lesions: basic science and clinical application of new surgical strategies. A review. Microsurgery 16:13161995

    • Search Google Scholar
    • Export Citation
  • 4

    Carlstedt TAnand PHallin RMisra PVNoren GSeferlis T: Spinal nerve root repair and reimplantation of avulsed ventral roots into the spinal cord after brachial plexus injury. J Neurosurg 93:2372472000

    • Search Google Scholar
    • Export Citation
  • 5

    Carlstedt TGrane PHallin RGNoren G: Return of function after spinal cord implantation of avulsed spinal nerve roots. Lancet 346:132313251995

    • Search Google Scholar
    • Export Citation
  • 6

    Cheng HCao YOlson L: Spinal cord repair in adult paraplegic rats: partial restoration of hind limb function. Science 273:5105131996

    • Search Google Scholar
    • Export Citation
  • 7

    Cheng HLiao KKLiao SFChuang TYShih YH: Spinal cord repair with acidic fibroblast growth factor as a treatment for a patient with chronic paraplegia. Spine 29:E284E2882004

    • Search Google Scholar
    • Export Citation
  • 8

    Cheng HShoung HMWu ZAChen KCLee LS: Functional connectivity of the transected brachial plexus after intercostal neurotization in monkeys. J Comp Neurol 380:1551631997

    • Search Google Scholar
    • Export Citation
  • 9

    Chuang TYChiou-Tan FYVennix MJ: Brachial plexopathy in gunshot wounds and motor vehicle accidents: comparison of electrophysiologic findings. Arch Phys Med Rehabil 79:2012041998

    • Search Google Scholar
    • Export Citation
  • 10

    Chuang TYHuang MCChen KCChang YCYen YSLee LS: Forelimb muscle activity following nerve graft repair of ventral roots in the rat cervical spinal cord. Life Sci 71:4874962002

    • Search Google Scholar
    • Export Citation
  • 11

    Fournier HDMenei PKhalifa RMercier P: Ideal intraspinal implantation site for the repair of ventral root avulsion after brachial plexus injury in humans. A preliminary anatomical study. Surg Radiol Anat 23:1911952001

    • Search Google Scholar
    • Export Citation
  • 12

    Fournier HDMercier PMenei P: Lateral interscalenic multilevel oblique corpectomies to repair ventral root avulsions after brachial plexus injury in humans: anatomical study and first clinical experience. J Neurosurg 95:2022072001

    • Search Google Scholar
    • Export Citation
  • 13

    Fournier HDMercier PMenei P: Repair of avulsed ventral nerve roots by direct ventral intraspinal implantation after brachial plexus injury. Hand Clin 21:1091182005

    • Search Google Scholar
    • Export Citation
  • 14

    Gu HYChai HZhang JYYao ZBZhou LHWong WM: Survival, regeneration and functional recovery of motoneurons after delayed reimplantation of avulsed spinal root in adult rat. Exp Neurol 192:89992005

    • Search Google Scholar
    • Export Citation
  • 15

    Gu YDCai PQXu FPeng FChen L: Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus. Microsurgery 23:1051082003

    • Search Google Scholar
    • Export Citation
  • 16

    Gu YXu JChen LWang HHu S: Long term outcome of contralateral C7 transfer: a report of 32 cases. Chin Med J (Engl) 115:8668682002

    • Search Google Scholar
    • Export Citation
  • 17

    Guest JDHesse DSchnell LSchwab MEBunge MBBunge RP: Influence of IN-1 antibody and acidic FGF-fibrin glue on the response of injured corticospinal tract axons to human Schwann cell grafts. J Neurosci Res 50:8889051997

    • Search Google Scholar
    • Export Citation
  • 18

    Hallin RGCarlstedt TNilsson-Remahl IRisling M: Spinal cord implantation of avulsed ventral roots in primates; correlation between restored motor function and morphology. Exp Brain Res 124:3043101999

    • Search Google Scholar
    • Export Citation
  • 19

    Hems TEBirch RCarlstedt T: The role of magnetic resonance imaging in the management of traction injuries to the adult brachial plexus. J Hand Surg [Br] 24:5505551999

    • Search Google Scholar
    • Export Citation
  • 20

    Hems TEClutton REGlasby MA: Repair of avulsed cervical nerve roots. An experimental study in sheep. J Bone Joint Surg Br 76:8188231994

    • Search Google Scholar
    • Export Citation
  • 21

    Hoffmann CFMarani Evan Dijk JGKamp WVDThomeer RT: Reinnervation of avulsed and reimplanted ventral rootlets in the cervical spinal cord of the cat. J Neurosurg 84:234 2431996

    • Search Google Scholar
    • Export Citation
  • 22

    Holtzer CAMarani ELakke EAThomeer RT: Repair of ventral root avulsions of the brachial plexus: a review. J Peripher Nerv Syst 7:2332422002

    • Search Google Scholar
    • Export Citation
  • 23

    Hsu SPShih YHHuang MCChuang TYHuang WCWu HM: Repair of multiple cervical root avulsion with sural nerve graft. Injury 35:8969072004

    • Search Google Scholar
    • Export Citation
  • 24

    Huang MCChen KCChuang TYChang WCLee LSHuang WC: Cervical root repair in adult rats after transection: recovery of forelimb motor function. Exp Neurol 180:101 1092003

    • Search Google Scholar
    • Export Citation
  • 25

    Jivan SNovikova LNWiberg MNovikov LN: The effects of delayed nerve repair on neuronal survival and axonal regeneration after seventh cervical spinal nerve axotomy in adult rats. Exp Brain Res 170:2452542006

    • Search Google Scholar
    • Export Citation
  • 26

    Kandenwein JAKretschmer TEngelhardt MRichter HPAntoniadis G: Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases. J Neurosurg 103:6146212005

    • Search Google Scholar
    • Export Citation
  • 27

    Kaptain GJSimmons NEReplogle REPobereskin L: Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy. J Neurosurg 93:1992042000

    • Search Google Scholar
    • Export Citation
  • 28

    Lee LMHuang MCChuang TYLee LSCheng HLee IH: Acidic FGF enhances functional regeneration of adult dorsal roots. Life Sci 74:193719432004

    • Search Google Scholar
    • Export Citation
  • 29

    Lee YSBaratta JYu JLin VWRobertson RT: AFGF promotes axonal growth in rat spinal cord organotypic slice cocultures. J Neurotrauma 19:3573672002

    • Search Google Scholar
    • Export Citation
  • 30

    Lee YSLin CYRobertson RTHsiao ILin VW: Motor recovery and anatomical evidence of axonal regrowth in spinal cord-repaired adult rats. J Neuropathol Exp Neurol 63:233 2452004

    • Search Google Scholar
    • Export Citation
  • 31

    Lee YSLin CYRobertson RTYu JDeng XHsiao I: Re-growth of catecholaminergic fibers and protection of cholinergic spinal cord neurons in spinal repaired rats. Eur J Neurosci 23:6937022006

    • Search Google Scholar
    • Export Citation
  • 32

    Lee YSSindhu RKLin CYEhdaie ALin VWVaziri ND: Effects of nerve graft on nitric oxide synthase, NAD(P)H oxidase, and antioxidant enzymes in chronic spinal cord injury. Free Radic Biol Med 36:3303392004

    • Search Google Scholar
    • Export Citation
  • 33

    Leechavengvongs SWitoonchart KUerpairojkit CThuvasethakul PMalungpaishrope K: Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg [Am] 31:1831892006

    • Search Google Scholar
    • Export Citation
  • 34

    Lin PHCheng HHuang WCChuang TY: Spinal cord implantation with acidic fibroblast growth factor as a treatment for root avulsion in obstetric brachial plexus palsy. J Chin Med Assoc 68:3923962005

    • Search Google Scholar
    • Export Citation
  • 35

    McGuiness CNKay SP: The prespinal route in contralateral C7 nerve root transfer for brachial plexus avulsion injuries. J Hand Surg [Br] 27:1591602002

    • Search Google Scholar
    • Export Citation
  • 36

    Moissonnier PDuchossoy YLavieille SHorvat JC: Lateral approach of the dog brachial plexus for ventral root reimplantation. Spinal Cord 36:3913981998

    • Search Google Scholar
    • Export Citation
  • 37

    Olson L: Grafts and growth factors in CNS. Basic science with clinical promise. Stereotact Funct Neurosurg 54–55:2502671990

  • 38

    Schwab ME: Experimental aspects of spinal cord regeneration. Curr Opin Neurol Neurosurg 6:5495531993

  • 39

    Schwab ME: Molecules inhibiting neurite growth: a minireview. Neurochem Res 21:7557611996

  • 40

    Schwab ME: Structural plasticity of the adult CNS. Negative control by neurite growth inhibitory signals. Int J Dev Neurosci 14:3793851996

    • Search Google Scholar
    • Export Citation
  • 41

    Schwab MECaroni P: Oligodendrocytes and CNS myelin are nonpermissive substrates for neurite growth and fibroblast spreading in vitro. J Neurosci 8:238123931988

    • Search Google Scholar
    • Export Citation
  • 42

    Terzis JKVekris MDSoucacos PN: Brachial plexus root avulsions. World J Surg 25:104910612001

  • 43

    Tsai ECDalton PDShoichet MSTator CH: Matrix inclusion within synthetic hydrogel guidance channels improves specific supraspinal and local axonal regeneration after complete spinal cord transection. Biomaterials 27:5195332006

    • Search Google Scholar
    • Export Citation
  • 44

    Tsai PYChuang TYCheng HWu HMChang YCWang CP: Concordance and discrepancy between electrodiagnosis and magnetic resonance imaging in cervical root avulsion injuries. J Neurotrauma 23:127412812006

    • Search Google Scholar
    • Export Citation
  • 45

    Wu JCHuang WCTsai YAChen YCCheng H: Nerve repair using acidic fibroblast growth factor in human cervical spinal cord injury: a preliminary Phase I clinical study. J Neurosurg Spine 8:2082142008

    • Search Google Scholar
    • Export Citation
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