Brachial plexus injury: factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion

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Object. Between 1994 and 1998, 44 nerve transfers were performed using a graft between a branch of the accessory nerve and musculocutaneous nerve to restore the flexion of the arm in patients with traumatic brachial plexus injuries. A retrospective study was conducted, including statistical evaluation of the following pre- and intraoperative parameters in 39 patients: 1) time interval between injury and surgery; and 2) length of the nerve graft used to connect the accessory and musculocutaneous nerves.

Methods. The postoperative follow-up interval ranged from 23 to 84 months, with a mean ± standard deviation of 36 ± 13 months. Reinnervation of the biceps muscle was achieved in 72% of the patients. Reinnervation of the musculocutaneous nerve was demonstrated in 86% of the patients who had undergone surgery within the first 6 months after injury, in 65% of the patients who had undergone surgery between 7 and 12 months after injury, and in only 50% of the patients who had undergone surgery 12 months after injury. A statistical comparison of the different preoperative time intervals (0–6 months compared with 7–12 months) showed a significantly better outcome in patients treated with early surgery (p < 0.05). An analysis of the impact of the length of the interposed nerve grafts revealed a statistically significant better outcome in patients with grafts 12 cm or shorter compared with that in patients with grafts longer than 12 cm (p < 0.005).

Conclusions. Together, these results demonstrated that outcome in patients who undergo accessory to musculocutaneous nerve neurotization for restoration of elbow flexion following brachial plexus injury is greatly dependent on the time interval between trauma and surgery and on the length of the nerve graft used.

Article Information

Address reprint requests to: Amir Samii, M.D., Ph.D., Department of Neurosurgery, Nordstadt Medical Center, Klinikum Hannover, Haltenhoffstrasse 41, 30167 Hannover, Germany. email: amir@samii.org.

© AANS, except where prohibited by US copyright law.

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Figures

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    Schematic drawing illustrating the principle of an accessory to musculocutaneous nerve transfer by using a sural nerve graft. Note that in completing the nerve transfer, a distal branch of the accessory nerve is used to spare as many branches as possible for the innervation of the trapezius muscle (TM). Solid thick line represents the lateral fascicle of the brachial plexus (proximally) and distal median nerve; solid thin line indicates the accessory nerve, with its course from the sternocleidomastoid muscle (SCM) to the TM; dotted line denotes the musculocutaneous nerve; and dashed line represents the sural nerve graft. BM = biceps muscle.

  • View in gallery

    Bar graph comparing functional (Grades M3–M5, black), nonfunctional (Grades M1–M2, gray), and nonexistent (Grade M0, white) restoration of biceps muscle strength (MRC scale) according to different preoperative time intervals. Functional recovery occurred more frequently in patients who had undergone surgery from 0 to 6 months following injury, compared with those who had undergone nerve transfer later than 6 months posttrauma.

  • View in gallery

    Bar graph comparing the different preoperative time intervals and the resulting mean biceps muscle strength (based on the MRC scale). Note the significantly better results (asterisk) in the group of patients who had undergone early surgery (0–6 months after injury) compared with those who had undergone surgery later (7–12 months after injury; p < 0.05).

  • View in gallery

    Bar graph comparing the different preoperative time intervals and the resulting mean biceps muscle strength (MRC scale) in patients in Groups I and II after excluding those who received nerve grafts longer than 12 cm. Note the better outcome in patients in Group I.

  • View in gallery

    Bar graph comparing different graft lengths and the resulting biceps muscle strength (based on the MRC scale) in patients who underwent surgery 7 to 12 months after injury. Note the highly significant difference between the two groups (p < 0.002). Patients who received shorter nerve grafts (≤ 12 cm) had a better outcome.

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