Brachial plexus neurotization with donor phrenic nerves and its effect on pulmonary function

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Object. To examine possible side effects of neurotizations in which the phrenic nerve was used, pulmonary function was analyzed pre- and postoperatively in patients with brachial plexus injury and root avulsions.

Methods. Twenty-three patients with complete brachial plexus palsy underwent neurotization of the musculocutaneous nerve, with the phrenic nerve as donor material. Patients who suffered lung contusions as part of the primary injury were excluded from this study. In 12 patients (five left-sided and seven right-sided neurotizations) pre- and postoperative functional parameters were compared and additional body plethysmography was performed more than 12 months postsurgery.

Of the 23, no patient experienced pulmonary problems postoperatively. Nonetheless, pulmonary functional parameters showed a vital capacity in percent of the predicted value of 9.8 ± 6.3% (mean ± standard deviation [SD]) in all patients examined, which was a significant reduction (p = 0.0002).

In right-sided phrenic nerve transfers this reduction was significant, at 14.3 ± 3.3% (mean ± SD), whereas left-sided transfers showed a nonsignificant reduction of 3.6 ± 3.5% (mean ± SD). The observed decrease in vital capacity (VC) correlates with the maximal inspiratory pressure (Pimax) as an indication of clinical significance.

Conclusions. When the right phrenic nerve is used as a donor in neurotization of the musculocutaneous nerve, the patient incurs a higher risk of reduced pulmonary VC. If possible, the left phrenic nerve should be preferred. The Pimax has to be determined preoperatively to avoid any further decrease in the already reduced pulmonary function due to the initial injury.

Article Information

Address reprint requests to: Wolf Luedemann, M.D., International Neuroscience Institute, Alexis-Carrel-Strasse 4, 30625, Hannover, Germany. email: Luedemann. Wolf@MH-Hannover.de.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graphs showing VC% according to the European Respiratory Society's guidelines before and after phrenic nerve transfer. Note the different course comparing left- (lower) and right-sided nerve transfers (upper). n = number of patients.

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    Box plot showing the decrease in VC% according to the European Respiratory Society's guidelines. The difference between left- and right-sided transfers is statistically significant. *p < 0.01. The black circle is an outlier.

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    Box plot showing postoperative Pimax in cm H2O after left- (li) and right-sided (re) phrenic nerve transfer. The difference is not significant. The white circles are outliers.

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    Scatterplot showing the regression curve of the difference between pre- and postoperative VC% and the postoperative Pimax. The regression curve follows the equation: Y = 105,508 − 1579 * X; R2 = 0.248; p = 0.1.

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