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R. Shane Tubbs, Mohammadali M. Shoja, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount, W. Jerry Oakes, and Bermans J. Iskandar

, and anatomical landmarks, such as the anterior scalene and phrenic nerves and the upper trunks of the brachial plexus, were identified. The triangle of the VA was carefully approached by retracting the SCM muscle medially, and the origin of the VA from the subclavian artery was identified ( Fig. 2 ). The VA was followed superiorly to its entrance into the C-6 transverse foramen. The C1–6 transverse foramina were palpated, and muscles overlying their lateral parts (for example, the anterior scalene and levator scapulae) were dissected using a periosteal dissector. In

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, E. George Salter, W. Jerry Oakes, and Jeffrey P. Blount

border of the trapezius muscle, and posterior border of the SCM muscle. Important structures within or adjacent to this geometric region include the spinal accessory nerve, proximal brachial plexus, phrenic nerve, and branches of the thyrocervical trunk (for example, the suprascapular and transverse cervical arteries). There were no injuries to any of these structures during the posterior approach to the vagus nerve in the cervical region; however, special care is necessary to avoid injury to, or excessive retraction on, the spinal accessory nerve, which is found

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Robert J. Spinner, Erik H. Middlebrooks, William R. Stetler Jr., Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount, and W. Jerry Oakes

T he suprascapular nerve is a branch of the upper trunk of the brachial plexus and is comprised of C-5 and sometimes C-6 ventral root fibers. This nerve travels through the posterior cervical triangle alongside the suprascapular artery and vein in a slightly deeper plane than the posterior belly of the omohyoid muscle as it proceeds toward the medial lip of the suprascapular notch. The suprascapular nerve and vessels become segregated as the nerve continues deep to the suprascapular ligament, and the vessels travel superficial to this band ( Fig. 1 ). In

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R. Shane Tubbs, Robert G. Louis Jr., Christopher T. Wartmann, Marios Loukas, Mohammadali M. Shoja, Mohammad R. Ardalan, and W. Jerry Oakes

of voluntary facial movement. 11 Some authors have reported unsatisfactory results, however, when using such standard nerves as the hypoglossal and spinal accessory nerves. 1 The majority of authors have agreed that the most important prognostic factor in facial reanimation is a tensionless anastomosis. 13 Considering the mediocre results demonstrated in association with currently available techniques, a search for alternative donor sites seemed plausible. To our knowledge, the suprascapular nerve and, for that matter, branches of the brachial plexus have not

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Mohammad R. Ardalan, Nihal Apaydin, Candice Myers, Ghaffar Shokouhi, and W. Jerry Oakes

S tandard anatomical texts state that the brachial plexus is contributed to by C5–T1 spinal nerves, 4 but recent studies have identified contributions from outside of this “normal” range. For example, Loukas et al. 8 found that 100% of their 150 cadaveric specimens had communications between T-2 and the brachial plexus. These connections were identified either intra- or extrathoracically and occurred in non-postfixed specimens (that is, a brachial plexus that is primarily composed of C6–T2 ventral rami). It is also known that the brachial plexus may have

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R. Shane Tubbs, William A. Shaffer, Marios Loukas, Mohammadali M. Shoja, and W. Jerry Oakes

then dissected distally onto the face. A subcutaneous tunnel was created with long hemostats, and the distally transected LTN was brought superiorly (deep to the clavicle and brachial plexus and axillary vessels) to the ipsilateral extracranial facial nerve at its exit from the stylomastoid foramen and also to its facial branches (the temporofacial and cervicofacial parts) where it was connected with a suture ( Fig. 4 ). In the posterior cervical triangle, the LTN innervation to the first 2 slips of the serratus anterior was left intact as this did not alter or

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R. Shane Tubbs, Marios Loukas, Mohammadali M. Shoja, Ghaffar Shokouhi, John C. Wellons III, W. Jerry Oakes, and Aaron A. Cohen-Gadol

T o our knowledge, the LTN has not been previously explored as a donor nerve for contralateral neurotization of the brachial plexus ( Fig. 1 ). With our recent findings of more than adequate length for using the ipsilateral LTN in neurotization to the ipsilateral facial nerve, we undertook the present study to evaluate the feasibility of using the LTN for contralateral neurotization to the musculocutaneous and suprascapular nerves in cadavers. F ig . 1. Artist's rendition of neurotization of the suprascapular and musculocutaneous nerves utilizing

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R. Shane Tubbs, William Stetler, Robert G. Louis Jr., Ankmalika A. Gupta, Marios Loukas, David R. Kelly, Mohammadali M. Shoja, and Aaron A. Cohen-Gadol

considering the other potential traction-prone nerves, it is sensible to consider them in 2 categories: spinal nerves and other CNs. In comparing the biomechanical stresses placed on spinal nerves as a result of limb movement, the most likely candidates that could be subject to traction forces are those of the brachial plexus. Specifically, one could argue that during shoulder abduction the roots, trunks, cords, or branches of the plexus could be subjected to similar traction forces. However, in this case, the stress is placed tangentially compared with the longitudinal

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R. Shane Tubbs, Tyler Marshall, Marios Loukas, Mohammadali M. Shoja, and Aaron A. Cohen-Gadol

C ompression of the median nerve is most common within the carpal tunnel. When there are signs of median nerve compression, carpal tunnel syndrome deserves first thought. 8 , 13 However, the median nerve may be compressed more proximally, and if this is not considered, an erroneous diagnosis may be made. 8 Other sites of potential compression of this nerve of the brachial plexus include at the lacertus fibrosus (bicipital aponeurosis), ligament of Struthers, between the heads of the pronator teres, by anomalous muscles such as an accessory head of the

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R. Shane Tubbs, Joshua M. Beckman, Marios Loukas, Mohammadali M. Shoja, and Aaron A. Cohen-Gadol

B ecause upper-limb dysfunction due to nerve injury is so significant, exploring novel methods of neurotization is worthwhile. For example, dysfunction of the radial nerve at the elbow results in wrist drop that is functionally debilitating as extension of the wrist joint is necessary for a strong grip. One neurotization method that has, to our knowledge, not been explored is median-to-radial nerve coaptation at the cubital fossa. The median nerve arises from both the medial and lateral cords of the brachial plexus, usually receiving fibers from all levels