Radial to axillary nerve neurotization for brachial plexus injury in children: a combined case series

Clinical article

View More View Less
  • 1 Departments of Neurological Surgery and
  • 4 Orthopaedic Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee;
  • 2 Department of Neurological Surgery, St. Louis Children's Hospital, Washington University, St. Louis, Missouri; and
  • 3 Pediatric Neurosurgery, Children's Hospital of Alabama, University of Alabama at Birmingham, Alabama
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Axillary nerve palsy, isolated or as part of a more complex brachial plexus injury, can have profound effects on upper-extremity function. Radial to axillary nerve neurotization is a useful technique for regaining shoulder abduction with little compromise of other neurological function. A combined experience of this procedure used in children is reviewed.

Methods

A retrospective review of the authors' experience across 3 tertiary care centers with brachial plexus and peripheral nerve injury in children (younger than 18 years) revealed 7 cases involving patients with axillary nerve injury as part of an overall brachial plexus injury with persistent shoulder abduction deficits. Two surgical approaches to the region were used.

Results

Four infants (ages 0.6, 0.8, 0.8, and 0.6 years) and 3 older children (ages 8, 15, and 17 years) underwent surgical intervention. No patient had significant shoulder abduction past 15° preoperatively. In 3 cases, additional neurotization was performed in conjunction with the procedure of interest. Two surgical approaches were used: posterior and transaxillary. All patients displayed improvement in shoulder abduction. All were able to activate their deltoid muscle to raise their arm against gravity and 4 of 7 were able to abduct against resistance. The median duration of follow-up was 15 months (range 8 months to 5.9 years).

Conclusions

Radial to axillary nerve neurotization improved shoulder abduction in this series of patients treated at 3 institutions. While rarely used in children, this neurotization procedure is an excellent option to restore deltoid function in children with brachial plexus injury due to birth or accidental trauma.

Abbreviation used in this paper:OBPP = obstetric brachial plexus palsy.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Scott L. Zuckerman, M.D., Department of Neurological Surgery, Vanderbilt University Medical Center, 2220 Children's Way, 9226 Doctors' Office Tower, Nashville, TN 37232-9557. email: scott.zuckerman@vanderbilt.edu.

Please include this information when citing this paper: published online September 5, 2014; DOI: 10.3171/2014.7.PEDS13435.

  • 1

    Alnot JY, , Rostoucher P, , Oberlin C, & Touam C: [C5-C6 and C5-C6-C7 traumatic paralysis of the brachial plexus of the adult caused by supraclavicular lesions]. Rev Chir Orthop Reparatrice Appar Mot 84:113123, 1998. (Fr)

    • Search Google Scholar
    • Export Citation
  • 2

    Alnot JY, & Valenti P: [Surgical repair of the axillary nerve. Apropos of 37 cases]. Int Orthop 15:711, 1991. (Fr)

  • 3

    Ashley WW Jr, , Baty JD, , Hollander T, , Noetzel MJ, & Park TS: Long-term motor outcome analysis using a motor score composite following surgical brachial plexus repair. J Neurosurg 106:4 Suppl 276281, 2007

    • Search Google Scholar
    • Export Citation
  • 4

    Bertelli JA, & Ghizoni MF: Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg Am 29:131139, 2004

    • Search Google Scholar
    • Export Citation
  • 5

    Bertelli JA, , Kechele PR, , Santos MA, , Duarte H, & Ghizoni MF: Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results. J Neurosurg 107:370377, 2007

    • Search Google Scholar
    • Export Citation
  • 6

    Birch R: Surgical Disorders of the Peripheral Nerves ed 2 London, Springer-Verlag, 2011

  • 7

    Bonnard C, , Anastakis DJ, , van Melle G, & Narakas AO: Isolated and combined lesions of the axillary nerve. A review of 146 cases. J Bone Joint Surg Br 81:212217, 1999

    • Search Google Scholar
    • Export Citation
  • 8

    Brown JM, , Shah MN, & Mackinnon SE: Distal nerve transfers: a biology-based rationale. Neurosurg Focus 26:2 E12, 2009

  • 9

    Chuang DC, , Lee GW, , Hashem F, & Wei FC: Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 96:122128, 1995

    • Search Google Scholar
    • Export Citation
  • 10

    Colbert SH, & Mackinnon S: Posterior approach for double nerve transfer for restoration of shoulder function in upper brachial plexus palsy. Hand (NY) 1:7177, 2006

    • Search Google Scholar
    • Export Citation
  • 11

    Dahlin LB, , Cöster M, , Björkman A, & Backman C: Axillary nerve injury in young adults—an overlooked diagnosis? Early results of nerve reconstruction and nerve transfers. J Plast Surg Hand Surg 46:257261, 2012

    • Search Google Scholar
    • Export Citation
  • 12

    Doumouchtsis SK, & Arulkumaran S: Is it possible to reduce obstetrical brachial plexus palsy by optimal management of shoulder dystocia?. Ann N Y Acad Sci 1205:135143, 2010

    • Search Google Scholar
    • Export Citation
  • 13

    Friedman AH, , Nunley JA II, , Goldner RD, , Oakes WJ, , Goldner JL, & Urbaniak JR: Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 72:5964, 1990

    • Search Google Scholar
    • Export Citation
  • 14

    Jerome JT: Anterior deltopectoral approach for axillary nerve neurotisation. J Orthop Surg (Hong Kong) 20:6670, 2012

  • 15

    Jerome JT: Long head of the triceps branch to axillary nerve in C5, C6 brachial plexus injuries: anterior approach. Plast Reconstr Surg 128:740741, 2011

    • Search Google Scholar
    • Export Citation
  • 16

    Jerome JT, & Rajmohan B: Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries. Microsurgery 32:445451, 2012

    • Search Google Scholar
    • Export Citation
  • 17

    Jobe MT, & Martinez SF, Peripheral nerve injuries. Canale ST, & Beaty JH: Campbell's Operative Orthopaedics ed 12 Philadelphia, Mosby, 2013. 30623123

    • Search Google Scholar
    • Export Citation
  • 18

    Kawai H, & Akita S: Shoulder muscle reconstruction in the upper type of the brachial plexus injury by partial radial nerve transfer to the axillary nerve. Tech Hand Up Extrem Surg 8:5155, 2004

    • Search Google Scholar
    • Export Citation
  • 19

    Kline DG, & Kim DH: Axillary nerve repair in 99 patients with 101 stretch injuries. J Neurosurg 99:630636, 2003

  • 20

    Kostas-Agnantis I, , Korompilias A, , Vekris M, , Lykissas M, , Gkiatas I, & Mitsionis G, : Shoulder abduction and external rotation restoration with nerve transfer. Injury [epub ahead of print], 2013

    • Search Google Scholar
    • Export Citation
  • 21

    Lee JY, , Kircher MF, , Spinner RJ, , Bishop AT, & Shin AY: Factors affecting outcome of triceps motor branch transfer for isolated axillary nerve injury. J Hand Surg Am 37:23502356, 2012

    • Search Google Scholar
    • Export Citation
  • 22

    Leechavengvongs S, , Witoonchart K, , Uerpairojkit C, & Thuvasethakul P: Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg Am 28:633638, 2003

    • Search Google Scholar
    • Export Citation
  • 23

    Leechavengvongs S, , Witoonchart K, , Uerpairojkit C, , Thuvasethakul P, & Malungpaishrope K: Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg Am 31:183189, 2006

    • Search Google Scholar
    • Export Citation
  • 24

    Lu J, , Xu J, , Xu W, , Xu L, , Fang Y, & Chen L, : Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach. Microsurgery 32:111117, 2012

    • Search Google Scholar
    • Export Citation
  • 25

    Lurje A: Concerning surgical treatment of traumatic injury to the upper division of the brachial plexus (Erb's type). Ann Surg 127:317326, 1948

    • Search Google Scholar
    • Export Citation
  • 26

    Malessy MJ, & Thomeer RT: Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery. J Neurosurg 88:266271, 1998

    • Search Google Scholar
    • Export Citation
  • 27

    Medical Research Council: Aids to the Investigation of Peripheral Nerve Injuries ed 2 London, Her Majesty's Stationery Office, 1943

  • 28

    Miller JH, , Garber ST, , McCormick DE, , Eskandari R, , Walker ML, & Rizk E, : Oberlin transfer and partial radial to axillary nerve neurotization to repair an explosive traumatic injury to the brachial plexus in a child: case report. Childs Nerv Syst 29:21052109, 2013

    • Search Google Scholar
    • Export Citation
  • 29

    Moore KL, , Dalley AF, & Agur AMR: Clinically Oriented Anatomy ed 5 Baltimore, Lippincott Williams & Wilkins, 2006

  • 30

    Nagano A: Treatment of brachial plexus injury. J Orthop Sci 3:7180, 1998

  • 31

    Narakas AO, Brachial plexus lesions. Leung PC, , Gu YD, & Ikuta Y, : Microsurgery in Orthopaedic Practice Singapore, World Scientific, 1995. 188254

    • Search Google Scholar
    • Export Citation
  • 32

    Narakas AO: Paralytic disorders of the shoulder girdle. Hand Clin 4:619632, 1988

  • 33

    Narakas AO, & Hentz VR: Neurotization in brachial plexus injuries. Indication and results. Clin Orthop Relat Res 237:4356, 1988

  • 34

    Nath RK, & Mackinnon SE: Nerve transfers in the upper extremity. Hand Clin 16:131139, ix, 2000

  • 35

    Oberlin C, , Béal D, , Leechavengvongs S, , Salon A, , Dauge MC, & Sarcy JJ: Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am 19:232237, 1994

    • Search Google Scholar
    • Export Citation
  • 36

    Ochiai N, , Nagano A, , Mikami Y, & Yamamoto S: Full exposure of the axillary and suprascapular nerves. J Bone Joint Surg Br 79:532533, 1997

    • Search Google Scholar
    • Export Citation
  • 37

    Okby R, & Sheiner E: Risk factors for neonatal brachial plexus paralysis. Arch Gynecol Obstet 286:333336, 2012

  • 38

    Payne MW, , Doherty TJ, , Sequeira KA, & Miller TA: Peripheral nerve injury associated with shoulder trauma: a retrospective study and review of the literature. J Clin Neuromuscul Dis 4:16, 2002

    • Search Google Scholar
    • Export Citation
  • 39

    Perlmutter GS: Axillary nerve injury. Clin Orthop Relat Res 368 2836, 1999

  • 40

    Piquilloud G, , Villani F, & Casoli V: The medial head of the triceps brachii. Anatomy and blood supply of a new muscular free flap: the medial triceps free flap. Surg Radiol Anat 33:415420, 2011

    • Search Google Scholar
    • Export Citation
  • 41

    Saito H, & Dahlin LB: Expression of ATF3 and axonal outgrowth are impaired after delayed nerve repair. BMC Neurosci 9:88, 2008

  • 42

    Samardzic M, , Grujicic D, & Antunovic V: Nerve transfer in brachial plexus traction injuries. J Neurosurg 76:191197, 1992

  • 43

    Samardzic M, , Grujicic D, , Rasulic L, & Bacetic D: Transfer of the medial pectoral nerve: myth or reality?. Neurosurgery 50:12771282, 2002

    • Search Google Scholar
    • Export Citation
  • 44

    Samardzić M, , Rasulić L, , Grujicić D, & Milicić B: Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 46:93103, 2000

    • Search Google Scholar
    • Export Citation
  • 45

    Schulz B, , Nyland J, , Keen J, & Malkani A: Self-reported shoulder function following massive rotator cuff tear reconstruction using a triceps brachii interposition flap. Acta Orthop Belg 74:582589, 2008

    • Search Google Scholar
    • Export Citation
  • 46

    Seddon HJ: Nerve grafting. J Bone Joint Surg Br 45:447461, 1963

  • 47

    Steinmann SP, & Moran EA: Axillary nerve injury: diagnosis and treatment. J Am Acad Orthop Surg 9:328335, 2001

  • 48

    Sundine MJ, & Malkani AL: The use of the long head of triceps interposition muscle flap for treatment of massive rotator cuff tears. Plast Reconstr Surg 110:12661274, 2002

    • Search Google Scholar
    • Export Citation
  • 49

    Terzis JK, & Kokkalis ZT: Shoulder function following primary axillary nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 122:14571469, 2008

    • Search Google Scholar
    • Export Citation
  • 50

    Tsuda Y, , Kanje M, & Dahlin LB: Axonal outgrowth is associated with increased ERK 1/2 activation but decreased caspase 3 linked cell death in Schwann cells after immediate nerve repair in rats. BMC Neurosci 12:12, 2011

    • Search Google Scholar
    • Export Citation
  • 51

    Visser CP, , Coene LN, , Brand R, & Tavy DL: The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg Br 81:679685, 1999

    • Search Google Scholar
    • Export Citation
  • 52

    Wellons JC, , Tubbs RS, , Pugh JA, , Bradley NJ, , Law CR, & Grabb PA: Medial pectoral nerve to musculocutaneous nerve neurotization for the treatment of persistent birth-related brachial plexus palsy: an 11-year institutional experience. Clinical article. J Neurosurg Pediatr 3:348353, 2009

    • Search Google Scholar
    • Export Citation
  • 53

    Witoonchart K, , Leechavengvongs S, , Uerpairojkit C, , Thuvasethakul P, & Wongnopsuwan V: Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study. J Hand Surg Am 28:628632, 2003

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 232 156 10
Full Text Views 334 8 3
PDF Downloads 287 18 13
EPUB Downloads 0 0 0