Return of spinal reflex after spinal cord surgery for brachial plexus avulsion injury

Case report

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Motor but not sensory function has been described after spinal cord surgery in patients with brachial plexus avulsion injury. In the featured case, motor-related nerve roots as well as sensory spinal nerves distal to the dorsal root ganglion were reconnected to neurons in the ventral and dorsal horns of the spinal cord by implanting nerve grafts. Peripheral and sensory functions were assessed 10 years after an accident and subsequent spinal cord surgery. The biceps stretch reflex could be elicited, and electrophysiological testing demonstrated a Hoffman reflex, or Hreflex, in the biceps muscle when the musculocutaneous nerve was stimulated. Functional MR imaging demonstrated sensory motor cortex activities on active as well as passive elbow flexion. Quantitative sensory testing and contact heat evoked potential stimulation did not detect any cutaneous sensory function, however. To the best of the authors' knowledge, this case represents the first time that spinal cord surgery could restore not only motor function but also proprioception completing a spinal reflex arch.

Abbreviations used in this paper: CHEPS = contact heat evoked potentials stimulation; DRG = dorsal root ganglion; fMR = functional MR; H-reflex = Hoffman reflex; QST = quantitative sensory testing.

Article Information

Address correspondence to: Thomas Carlstedt, M.D., Ph.D., The Peripheral Nerve Injury Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, United Kingdom. email:

Please include this information when citing this paper: published online August 12, 2011; DOI: 10.3171/2011.7.JNS111106.

© AANS, except where prohibited by US copyright law.



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    Photomicrograph showing biceps muscle biopsy specimen from the affected arm, immunostained with antibodies to the structural nerve marker PGP 9.5. Bar = 50 μm.

  • View in gallery

    Tracings of the H-reflex from the biceps muscle. The uppermost trace is the M response, whereas the lower 3 traces show reproducible H-reflexes from the biceps muscle.

  • View in gallery

    Coronal (left) and axial (right) fMR images demonstrating activation during active and passive arm movements. Red, left arm active; yellow, left arm passive; blue, right arm active; and green, right arm passive.



Atherton DDFacer PRoberts KMMisra VPChizh BABountra C: Use of the novel Contact Heat Evoked Potential Stimulator (CHEPS) for the assessment of small fibre neuropathy: correlations with skin flare responses and intraepidermal nerve fibre counts. BMC Neurol 7:21312007


Carlstedt T: Central Nerve Plexus Injury LondonImperial College Press2007. 139166


Carlstedt TAldskogius HRosario C: Extension of dorsal horn neurons into the severed and implanted dorsal root. Restor Neurol Neurosci 3:2052091991


Carlstedt TAnand PHtut MMisra PSvensson M: Restoration of hand function and the “breathing arm” from spinal cord repair of C5–T1 brachial plexus avulsion injury. Case report. Neurosurg Focus 16:5E72004


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


Carlstedt THultgren TNyman THansson T: Cortical activity and hand function restoration in a patient after spinal cord surgery. Nat Rev Neurol 5:5715742009


Cullheim SCarlstedt TLindå HRisling MUlfhake B: Motoneurons reinnervate skeletal muscle after ventral root implantation into the spinal cord of the cat. Neuroscience 29:7257331989


Cullheim SCarlstedt TRisling M: Axon regeneration of spinal motoneurons following a lesion at the cord-ventral root interface. Spinal Cord 37:8118191999


Lindå HRisling MCullheim S: ‘Dendraxons’ in regenerating motoneurons in the cat: do dendrites generate new axons after central axotomy?. Brain Res 358:3293331985




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