Johannes A. Mayer, Laura A. Hruby, Stefan Salminger, Gerd Bodner and Oskar C. Aszmann
Spinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle.
Five cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented.
All 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients.
Restoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.
Mustafa Nadi and Rajiv Midha
Laura A. Hruby, Agnes Sturma, Johannes A. Mayer, Anna Pittermann, Stefan Salminger and Oskar C. Aszmann
Global brachial plexus lesions with multiple root avulsions are among the most severe nerve injuries, leading to lifelong disability. Fortunately, in most cases primary and secondary reconstructions provide a stable shoulder and restore sufficient arm function. Restoration of biological hand function, however, remains a reconstructive goal that is difficult to reach. The recently introduced concept of bionic reconstruction overcomes biological limitations of classic reconstructive surgery to restore hand function by combining selective nerve and muscle transfers with elective amputation of the functionless hand and its replacement with a prosthetic device. The authors present their treatment algorithm for bionic hand reconstruction and report on the management and long-term functional outcomes of patients with global brachial plexopathies who have undergone this innovative treatment.
Thirty-four patients with posttraumatic global brachial plexopathies leading to loss of hand function consulted the Center for Advanced Restoration of Extremity Function between 2011 and 2015. Of these patients, 16 (47%) qualified for bionic reconstruction due to lack of treatment alternatives. The treatment algorithm included progressive steps with the intent of improving the biotechnological interface to allow optimal prosthetic hand replacement. In 5 patients, final functional outcome measurements were obtained with the Action Arm Research Test (ARAT), the Southampton Hand Assessment Procedure (SHAP), and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.
In all 5 patients who completed functional assessments, partial hand function was restored with bionic reconstruction. ARAT scores improved from 3.4 ± 4.3 to 25.4 ± 12.7 (p = 0.043; mean ± SD) and SHAP scores improved from 10.0 ± 1.6 to 55 ± 19.7 (p = 0.042). DASH scores decreased from 57.9 ± 20.6 to 32 ± 28.6 (p = 0.042), indicating decreased disability.
The authors present an algorithm for bionic reconstruction leading to useful hand function in patients who lack biological treatment alternatives for a stiff, functionless, and insensate hand resulting from global brachial plexopathies.