Dual reinnervation of biceps muscle after side-to-side anastomosis of an intact median nerve and a damaged musculocutaneous nerve

Case report

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Traumatic peripheral nerve injury can lead to significant long-term disability for previously healthy persons. Damaged nerve trunks have been traditionally repaired using cable grafts, but nerve transfer or neurotization procedures have become increasingly popular because the axonal regrowth distances are much shorter. These techniques sacrifice the existing nerve pathway, so muscle reinnervation depends entirely on the success of the repair. Providing a supplemental source of axons from an adjacent intact nerve by using side-to-side anastomosis might reinnervate the target muscle without compromising the function of the donor nerve.

The authors report a case of biceps muscle reinnervation after side-to-side anastomosis of an intact median nerve to a damaged musculocutaneous nerve. The patient was a 34-year-old man who had sustained traumatic injury primarily to the right upper and middle trunks of the brachial plexus. At 9 months after the injury, because of persistent weakness, the severely damaged upper trunk of the brachial plexus was repaired with an end-to-end graft. When 8 months later biceps function had not recovered, the patient underwent side-to-side anastomosis of the intact median nerve to the adjacent distal musculocutaneous nerve via epineural windows. By 9 months after the second surgery, biceps muscle function had returned clinically and electrodiagnostically. Postoperative electromyographic and nerve conduction studies confirmed that the biceps muscle was being reinnervated partly by donor axons from the healthy median nerve and partly by the recovering musculocutaneous nerve.

This case demonstrates that side-to-side anastomosis of an intact median to an injured musculocutaneous nerve can provide dual reinnervation of the biceps muscle while minimizing injury to both donor and recipient nerves.

Article Information

Address correspondence to: Michel Kliot, M.D., Department of Neurological Surgery, University of California San Francisco, Room M780, Box 0112, 505 Parnassus Ave., San Francisco, CA 94143-0112. email: KliotM@neurosurg.ucsf.edu.

Please include this information when citing this paper: published online June 14, 2013; DOI: 10.3171/2013.5.JNS122359.

© AANS, except where prohibited by US copyright law.

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Figures

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    Operative position for right brachial plexus exploration surgery (A). Isolation of musculocutaneous (B, lateral, marked by yellow vessel loops) and median (C, medial, marked by white vessel loop) nerves. Approximation (D) and suturing (E) of the median and musculocutaneous nerves for side-to-side anastomosis. Side-to-side anastomosis completed and wrapped in Surgicel and covered with Tisseel fibrin glue (F).

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    Neurophysiological studies performed 9 months after side-to-side anastomosis of an intact median nerve and a damaged musculocutaneous nerve. A: Electrical stimulation of the median nerve was performed at the elbow and wrist with a recording concentric needle electrode in the biceps muscle. B: Late responses were present with stimulation of the median nerve at both sites at a latency of 59.2 msec with stimulation at the elbow and 66.0 msec with stimulation at the wrist (8 consecutive traces superimposed). C: Concentric needle electromyography (EMG) recordings from the biceps and flexor carpi radialis (FCR) muscles were obtained simultaneously by using 2-channel recordings. Sparse motor units in the biceps muscle were noted when the patient was asked to flex the elbow. D: When the patient was asked to flex only the wrist, a moderate number of biceps muscle motor units were coactivated. E: When the patient was asked to flex the wrist and elbow together, a more dense interference pattern was identified. n. = nerve; stim. = stimulation site.

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