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Jayme A. Bertelli and Marcos F. Ghizoni

OBJECTIVE

The purpose of this paper was to report the authors' results with finger flexion restoration by nerve transfer in patients with tetraplegia.

METHODS

Surgery was performed for restoration of finger flexion in 17 upper limbs of 9 patients (8 male and 1 female) at a mean of 7.6 months (SD 4 months) after cervical spinal cord injury. The patients' mean age at the time of surgery was 28 years (SD 15 years). The motor level according to the ASIA (American Spinal Injury Association) classification was C-5 in 4 upper limbs, C-6 in 10, and C-7 in 3.

In 3 upper limbs, the nerve to the brachialis was transferred to the anterior interosseous nerve (AIN), which was separated from the median nerve from the antecubital fossa to the midarm. In 5 upper limbs, the nerve to the brachialis was transferred to median nerve motor fascicles innervating finger flexion muscles in the midarm. In 4 upper limbs, the nerve to the brachioradialis was transferred to the AIN. In the remaining 5 upper limbs, the nerve to the extensor carpi radialis brevis (ECRB) was transferred to the AIN. Patients were followed for an average of 16 months (SD 6 months). At the final evaluation the range of finger flexion and strength were estimated by manual muscle testing according to the British Medical Research Council scale.

RESULTS

Restoration of finger flexion was observed in 4 of 8 upper limbs in which the nerve to the brachialis was used as a donor. The range of motion was incomplete in all 5 of these limbs, and the strength was M3 in 3 limbs and M4 in 1 limb. Proximal retrograde dissection of the AIN was associated with better outcomes than transfer of the nerve to the brachialis to median nerve motor fascicles in the arm. After the nerve to the brachioradialis was transferred to the AIN, incomplete finger flexion with M4 strength was restored in 1 limb; the remaining 3 limbs did not show any recovery. Full finger flexion with M4 strength was demonstrated in all 5 upper limbs in which the nerve to the ECRB was transferred to the AIN. No functional downgrading of elbow flexion or wrist extension strength was observed.

CONCLUSIONS

In patients with tetraplegia, finger flexion can be restored by nerve transfer. Nerve transfer using the nerve to the ECRB as the donor nerve produced better recovery of finger flexion in comparison with nerve transfer using the nerve to the brachialis or brachioradialis.

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Jayme A. Bertelli and Marcos F. Ghizoni

✓ Brachial plexus avulsion injuries are a clinical challenge. In recent experimental studies the authors have demonstrated the high degree of muscle reinnervation attained when a C-4 motor rootlet was directly connected to the musculocutaneous nerve. This degree of reinnervation was attributed to the good chance that a muscle fiber can be reinnervated by a motor fiber when the number of regenerating motor neurons is increased and when competitive sensory fibers are excluded from the process. The authors present the first clinical case in which this phenomenon has been observed. This 26-year-old man, who was involved in an automobile accident, presented with an upper brachial plexus avulsion, for which he underwent operation 4 months later. The axillary and suprascapular nerves were directly surgically connected to the motor rootlets of the C-7 contralateral root by using two cables of sural nerve graft. Two years postsurgery, the patient was able to perform shoulder abduction of 120° and hold an 800-g weight at 90°. These results are encouraging, and in selected patients motor rootlet transfer might prove to be a useful surgical strategy.

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Letter to the Editor

Brachial plexus palsy

Jayme A. Bertelli

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Jayme A. Bertelli, Neehar Patel, Francisco Soldado, and Elisa Cristiana Winkelmann Duarte

OBJECTIVE

The purpose of this study was to describe the anatomy of donor and recipient median nerve motor branches for nerve transfer surgery within the cubital fossa.

METHODS

Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery.

RESULTS

In the cubital fossa, the first branch was always the proximal branch of the pronator teres (PPT), whereas the last one was the anterior interosseous nerve (AIN) and the distal motor branch of the flexor digitorum superficialis (DFDS) on a consistent basis. The PT muscle was also innervated by a distal branch (DPT), which emerged from the anterior side of the median nerve and provided innervation to its deep head. The palmaris longus (PL) motor branch was always the second branch after the PPT, emerging as a single branch together with the flexor carpi radialis (FCR) or the proximal branch of the flexor digitorum superficialis. The FCR motor branch was prone to variations. It originated proximally with the PL branch (35%) or distally with the AIN (35%), and less frequently from the DPT. In 40% of dissections, the FDS was innervated by a single branch (i.e., the DFDS) originating close to the AIN. In 60% of cases, a proximal branch originated together with the PL or FCR. The AIN emerged from the posterior side of the median nerve and had a diameter of 2.3 mm, twice that of other branches. When dissections were performed between the PT and FCR muscles at the FDS arcade, we observed the AIN lying lateral and the DFDS medial to the median nerve. After crossing the FDS arcade, the AIN divided into: 1) a lateral branch to the flexor pollicis longus (FPL), which bifurcated to reach the anterior and posterior surfaces of the FPL; 2) a medial branch, which bifurcated to reach the flexor digitorum profundus (FDP); and 3) a long middle branch to the pronator quadratus. The average numbers of myelinated fibers within each median nerve branch were as follows (values expressed as the mean ± SD): PPT 646 ± 249; DPT 599 ± 150; PL 259 ± 105; FCR 541 ± 199; proximal FDS 435 ± 158; DFDS 376 ± 150; FPL 480 ± 309; first branch to the FDP 397 ± 12; and second branch to the FDP 369 ± 33.

CONCLUSIONS

The median nerve's branching pattern in the cubital fossa is predictable. The most important variation involves the FCR motor branch. These anatomical findings aid during nerve transfer surgery to restore function when paralysis results from injury to the radial or median nerves, brachial plexus, or spinal cord.