T he incidence of birth-related brachial plexus injuries varies from one to two per 1000 live births. 14 Conventional treatment of these injuries involves an arbitrary period of repeated evaluation. 2, 5, 8, 10, 11, 13, 16, 18, 20, 22, 25, 27, 29 The infants who show functional improvement continue with conservative therapy; operative correction is undertaken in those showing little or no improvement in the affected muscle groups 3 to 6 months after birth. These treatment decisions based on neurological examination have been adopted because preoperative
Paul C. Francel, Myles Koby, T. S. Park, Benjamin C. P. Lee, Michael J. Noetzel, Susan E. Mackinnon, Martin M. Henegar and Bruce A. Kaufman
Susan E. Mackinnon
hundred and seventy-five cases. Surg Gynecol Obstet 39 : 543 – 553 , 1924 Delagénière H: A contribution to the study of the surgical repair of peripheral nerves. Based on three hundred and seventy-five cases. Surg Gynecol Obstet 39: 543–553, 1924 17. Doi K , Sakai K , Kuwata N , et al : Double free-muscle transfer to restore prehension following complete brachial plexus avulsion. J Hand Surg (Am) 20 : 408 – 414 , 1995 Doi K, Sakai K, Kuwata N, et al: Double free-muscle transfer to restore prehension
Thomas H. Tung, Christine B. Novak and Susan E. Mackinnon
N erve transfers are commonly used in the reconstruction of brachial plexus injuries when root avulsion has occurred or when the lesion is very proximal. 5, 6, 15, 18, 19, 24 Many techniques and donor nerves have been described, and the most appropriate choice depends on the level of the lesion and the availability of donor motor nerves. 2, 11, 16, 17, 20, 21 In 1994, Oberlin, et al., 22 reported the transfer of a redundant FCU fascicle from the functioning ulnar nerve directly to the biceps branch of the musculocutaneous nerve to restore elbow flexion
Thomas H. Tung, Christine B. Novak and Susan E. Mackinnon
In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent nerve transfers to the biceps and the brachialis branches of the musculocutaneous nerve.
The charts of eight patients who underwent an ulnar nerve fascicle transfer to the biceps branch of the musculocutaneous nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG).
The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar nerve function was not downgraded in any patient.
The use of nerve transfers to reinnervate the biceps and brachialis muscle provides excellent elbow flexion strength in patients with brachial plexus nerve injuries.
Case report and review of the literature
Thomas H. Tung, D. Zachary Martin, Christine B. Novak, Carl Lauryssen and Susan E. Mackinnon
cases of spinal root avulsion occurred proximal to the spinal ganglia and distal to the lumbar enlargement of the spinal cord. Also, the distal stumps were observed to have been pulled through the intervertebral foramina and were not visible at the time of laminectomy. The author concluded that the force of action in lumbosacral root avulsion is coaxial with the spinal cord rather than perpendicular, as in the case of cervical root avulsion in brachial plexus injuries, and that this explained the existence of a significant postganglionic ventral root following
Susan E. Mackinnon, Brandon Roque and Thomas H. Tung
I njury to the radial nerve in the upper extremity is common 2 and can result from orthopedic injuries or their surgical management, 17 , 31 , 45 direct nerve trauma, 3 , 18 , 37 as part of a brachial plexus injury, 26 , 32 , 54 or nerve compression. 1 , 29 , 36 , 41 , 47 Radial nerve palsy may also be caused by nerve tumors, 26 local inflammation, 30 , 44 , 61 or idiopathic neuritis. 46 , 50 The most appropriate management will depend on the cause, the level and extent of the injury or lesion, the degree of functional impairment, and the duration
Justin M. Brown, Manish N. Shah and Susan E. Mackinnon
at restoring distal brachial plexus function using nerve transfers and proximal grafting. 19 , 32 The pitfalls of more proximal grafting are that fewer axons effectively innervate their target end organs because of the distance of axon growth and the multifunctionality of the transfer nerve with the variable motor and sensory fascicular topography. 6 Distal nerve transfers address these obstacles by grafting to more oligo- or monofunctional nerve branches at a short distance from the target organ. Oberlin's transfer of a fascicle of the ulnar nerve directly to
Wilson Z. Ray, Mitchell A. Pet, Andrew Yee and Susan E. Mackinnon
B rachial plexus injuries are rare but catastrophic events that result in the partial or total loss of motor and sensory function in the upper extremity. These debilitating injuries involve young male patients 90% of the time, 29 , 42 and up to 84% of the injuries are sustained in motorcycle accidents. 10 The task of reconstructing the traumatized brachial plexus can be complex and daunting, yet the use of nerve transfers and an increased understanding of peripheral nerve biology has provided the field with a recent period of rapid evolution
Nicholas M. Barbaro
Neurosurgeons who treat patients with peripheral nerve injuries face the challenge of deciding if and when to operate. This is especially true when the mechanism of injury is stretch. The most challenging cases are brachial plexus injuries in which the functional loss is disabling and the distance from the site of injury to the denervated muscles is far. The standard approach is to monitor patients for approximately 3 months before making a decision to operate or to continue waiting. As the average rate of nerve recovery is approximately 1 inch per month