End-to-side neurorrhaphy in brachial plexus reconstruction

Clinical article

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Although a number of theoretical and experimental studies dealing with end-to-side neurorrhaphy (ETSN) have been published to date, there is still a considerable lack of clinical trials investigating this technique. Here, the authors describe their experience with ETSN in axillary and musculocutaneous nerve reconstruction in patients with brachial plexus palsy.


From 1999 to 2007, out of 791 reconstructed nerves in 441 patients treated for brachial plexus injury, the authors performed 21 axillary and 2 musculocutaneous nerve sutures onto the median, ulnar, or radial nerves. This technique was only performed in patients whose donor nerves, such as the thoracodorsal and medial pectoral nerves, which the authors generally use for repair of axillary and musculocutaneous nerves, respectively, were not available. In all patients, a perineurial suture was carried out after the creation of a perineurial window.


The overall success rate of the ETSN was 43.5%. Reinnervation of the deltoid muscle with axillary nerve suture was successful in 47.6% of the patients, but reinnervation of the biceps muscle was unsuccessful in the 2 patients undergoing musculocutaneous nerve repair.


The authors conclude that ETSN should be performed in axillary nerve reconstruction but only when commonly used donor nerves are not available.

Abbreviations used in this paper:EMG = electromyography; ETSN = end-to-side neurorrhaphy; MRC = Medical Research Council.

Article Information

Address correspondence to: Pavel Haninec, M.D., Ph.D., 3rd Faculty of Medicine, Charles University, Department of Neurosurgery, Hospital Kralovske Vinohrady, Srobarova 50, 100 34 Prague, Czech Republic. email: pavel.haninec@fnkv.cz.

Please include this information when citing this paper: published online July 12, 2013; DOI: 10.3171/2013.6.JNS122211.

© AANS, except where prohibited by US copyright law.



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    Artist's drawings of ETSN of the axillary nerve onto the ulnar nerve. Preparation of the distal stump of the axillary nerve (a.n.) (A and B) and its suture (C) onto the perineurial window (p.w.) of the ulnar nerve (u.n.) on the right side. The anatomy of the axilla is simplified; the musculocutaneous nerve is hidden behind the axillary and brachial arteries, and other small nerve branches of the brachial plexus are not shown. m.n. = median nerve; r.n. = radial nerve; s.a. = subscapular artery; t.d.n. = thorocodorsal nerve.

  • View in gallery

    Intraoperative photographs of ETSN. A: Creation of the perineurial window (perineurium is held in the tweezer); axillary nerve (1, arrow) and ulnar nerve (2) are visible. B: Suture (arrow) of the distal stump of the axillary nerve (1) onto the perineurial window of the ulnar nerve (2) on the right side.

  • View in gallery

    Patient 3. The photograph was taken 37 months postoperatively showing success of ETSN on the right side.

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    The authors' algorithm for upper plexus palsy surgery when patients present with avulsion or high rupture of C5–6 roots. Spinal accessory, thoracodorsal, and medial pectoral nerves are the most commonly used donors for neurotization. If these nerves are unavailable, other donor nerves should be used according to their quality. The ETSN technique should be performed only as the last option in axillary nerve reconstruction when none of the other neurotization techniques can be used.



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