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Brachial plexus repair by peripheral nerve grafts directly into the spinal cord in rats

Behavioral and anatomical evidence of functional recovery

Jayme Augusto Bertelli and Jean Claude Mira

of promoting spinal cord repair. Richardson, et al. , 29 Aguayo, et al. , 1 and Sceats, et al. , 32 demonstrated that spinal axons could regrow in implanted peripheral nerve grafts. Horvat, et al. , 21, 22 reported the formation of functional endplates via regeneration of spinal axons through a peripheral nerve graft implanted into the spinal cord. Both traumatic injuries to the spinal cord and avulsion injuries to the brachial plexus are considered lesions of the CNS. 11 The positive results obtained for the repair of avulsion injuries by the insertion

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Jayme Augusto Bertelli, Jean Claude Mira, Monique Pecot-Dechavassine and Alain Sebille

W hen nerve roots of the brachial plexus are avulsed from the spinal cord, they do not spontaneously regenerate. 10, 16 Instead, the muscles innervated by these roots become permanently paralyzed. 9, 34 In some patients, nerve transfer using intercostal nerves, 17, 38 accessory nerve, 1 cervical plexus, 11 or C3–4 anterior rami 41 to the musculocutaneous nerve or suprascapular nerves has been shown to restore some useful functions. Nevertheless, the results are still limited. 2 Sensory fibers, which reach a muscle fiber by misdirection following

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Jayme Augusto Bertelli, Marcos Flavio Ghizoni and Adalberto Michels

, preserving C-6, or alternatively with partial dorsal rhizotomy of all the aforementioned roots. We demonstrated in rats that the proprioceptive neurons are located at the same level of the motor neuron pool. 7 Based on this anatomical knowledge, in the present study, when the patient's shoulder and elbow were observed to be spastic on clinical examination, the C-5 and C-6 dorsal roots were completely divided. When the wrist and fingers were spastic, C-7 and C-8 dorsal rhizotomies were performed. To our knowledge, no clinical series of brachial plexus dorsal rhizotomy for

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Jayme Augusto Bertelli and Marcos Flávio Ghizoni

contralateral C-4 motor rootlet and directly implanted deep into the biceps muscle. This patient had, previous to brachial plexus surgery, an arm replantation. The phrenic nerve was transferred to the musculocutaneous nerve in two patients by using 10- and 14-cm-long grafts and to the anterior division of the upper trunk after ligature of the lateral root of the median nerve in two other patients. In this last situation, the nerve grafts were very short (2 and 3 cm). Table 1 provides a summary of data on the nerve and motor rootlet transfers used in cases of partial and

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Jayme Augusto Bertelli and Marcos Flávio Ghizoni

C omplete brachial plexus lesion is a dramatic condition that usually affects young adult victims of motorcycle accidents. Closed traction lesions, by far the most common, 23 may damage the brachial plexus not only in the supraclavicular zone (that is, root rupture) but also intradurally at the cord level (that is, root avulsion). In cases of root rupture, the proximal stump of the burst root remains attached to the spinal cord, whereas in cases of avulsion, the root is torn away from the spinal cord and there is no proximal stump. Generally, the pattern

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Jayme Augusto Bertelli, Paulo Roberto Kechele, Marcos Antonio Santos, Hamilton Duarte and Marcos Flávio Ghizoni

I solated injury to the axillary nerve can occur because of shoulder dislocation or from inadvertent lesions during surgery, or it may be part of a more complex lesion such as a brachial plexus palsy. 2 , 6 , 12 , 18 , 20 , 27 , 30 Axillary nerve injuries lead to abduction and external rotation weakness. 2 , 15 In brachial plexus injuries, shoulder motion is affected in 95% of cases, and the concomitant involvement of the axillary and suprascapular nerves, due to root lesions, culminates in total palsy on abduction and external rotation. 1 In isolated

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Jayme Augusto Bertelli, Paulo Roberto Kechele, Marcos Antonio Santos, Bruno Adler Maccagnan Pinheiro Besen and Hamilton Duarte

I n lower-type nerve palsies of the brachial plexus, shoulder and elbow motion largely remain preserved, whereas hand function is considerably impaired. Particularly in C7–T1 lesions, one observes a lack of finger flexion and intrinsic muscle control, as well as the absence of thumb and finger extension. Innervation of the extensor carpi radialis longus and brevis is partially preserved; hence, wrist extension is spared, but is weak. The extensor carpi ulnaris is paralyzed, and when extended, the wrist deviates radially. Pronation is sustained because the

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Jayme Augusto Bertelli and Marcos Flavio Ghizoni

A fter brachial plexus injuries, when only C7–T1 roots are involved, there is normal shoulder and elbow motion with marked palsy in the hand. Wrist motion is largely preserved, but finger motion is abolished. 1 Thus, in these patients, surgery aims at reconstructing finger and thumb flexion/extension. For finger flexion reconstruction, we have successfully used transfers of the brachialis muscle, prolonged by a tendon graft, to the flexor digitorum profundus and flexor pollicis longus. 4 For finger extension reconstruction, we have initially and

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Jayme Augusto Bertelli, Marcos Flávio Ghizoni and Cristiano Paulo Tacca

majority of patients only recover enough strength to resist gravity. 7 Despite their widespread use in brachial plexus reconstruction, distal nerve transfers have only recently been applied in tetraplegia. We have successfully transferred the supinator motor branch to the posterior interosseous nerve to reconstruct thumb and finger extension. 4 In a recent anatomical study, we observed that either the teres minor motor branch or the posterior deltoid motor branch is suitable for transfer to triceps motor branches. 3 In the present case, we report using the teres minor

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Jayme Augusto Bertelli and Marcos Flávio Ghizoni

A fter stretch injuries of the brachial plexus, the extent of paralysis depends on which roots have been injured. In 1949, Barnes 1 reviewed 63 closed injuries of the brachial plexus and classified them into 4 types of palsy: C5–6, C5–7, C5–T1, and C7–T1. In the C5–6 group, paralysis affects shoulder abduction/external rotation and elbow flexion. When C-7 is also injured, in addition to C5–6 deficits, elbow, wrist, and thumb and finger extension are paralyzed. This view continues to be widely held today. 12 , 14 Our knowledge regarding myotomes