Brachial Plexus repair with Nerve transfer.

1. Scientific Article |
The Role of Nerve Transfers for C5-C6 Brachial Plexus
Injury in Adults
Matthew J. Schessler, MS-III instrumentation, coupled with further investigators in three ways. First,
West Virginia University School of understanding of nerve anatomy, DaVinci approached the human
Medicine
significant strides have been made cadaver in a methodical fashion,
W.Thomas McClellan, M.D.
Plastic and Upper Extremity Surgeon to improve nerve transfer outcome. noting every anatomical nuance.
Morgantown Plastic Surgery Associates Secondly, his mechanical prowess
led him to postulate on the function
History of Brachial Plexus of that which he was dissecting.
Abstract Injuries and Reconstruction Finally and most importantly he
The brachial plexus consists of nerve
Brachial plexus injuries have used his artistic talent to create a
roots C5 – T1. Upper brachial plexus
roots (C5-C6) innervate proximal muscles been a reported directly or detailed and vibrant anatomical
of the shoulder and upper arm. Injuries indirectly for the last 2800 years. reference for future work.
causing root avulsion or rupture require The first mention of a brachial In 1824 French physiologist Marie
intensive treatment and significantly plexus injury in literature occurs in Jean Pierre Flourens was the first to
impact patients’ quality of life. Nerves Homer’s The Iliad around 800BC.1 theorize that an injured nerve could
regenerate extremely slowly and without Although sporadic mention of be bypassed, “joining the superior
treatment, patients with upper brachial
plexus injuries is scattered in the end of one nerve with the inferior end
plexus lesions may lose motor function
distal to the injury. Upper brachial plexus early literature little anatomical of the other and visa versa.”3-4
reconstruction using nerve transfers is a dissection or description took place But it wasn’t until 1948 when
new method to bypass damaged areas during the next thousand years. Alexander Lurje, a Russian surgeon,
thereby allowing patients to regain critical In 1507 Leonardo DaVinci performed the first brachial
arm functions faster. We present a review performed a detailed dissection plexus reconstruction using nerve
of brachial plexus cadaveric anatomy,
of a 100 year old man who had transfers on a 20 year old female
reconstruction transfer techniques, and
management.
died of natural causes. This initial injured by a Nazi bomb blast.5
experience led him to sketch the Remarkably he was able to perform
Introduction now famous illustrations entitled the procedure prior to the advent
“del Vecchio” and perform over of microsurgical equipment,
The upper brachial plexus
30 detailed human dissections. instruments, or technique.
roots (C5-C6) innervate proximal
DaVinci’s impact on modern Over the last 20 years our
arm muscles controlling shoulder
anatomy differed from prior improved understanding of nerve
abduction, elbow flexion and
contribute to the innervation of distal
muscles controlling limb function.
Upper root avulsions are devastating Figure 1.
injuries because the patient loses Description and artist’s rendition of Hector’s altercation with Teucer resulting in
the critical functions of shoulder a brachial plexus injury.1
abduction and elbow flexion. Even
“Hector sprang from his chariot to
if distal innervation is unaffected
the ground, and seizing a great stone
(C7-T1), without shoulder and elbow made straight for Teucer with intent
stability the wrist and hand cannot to kill him…Hector struck him with
perform daily activities. Repairing the jagged stone….he hit him where
these avulsed roots presents a the collar bone divides the neck from
the chest, a very deadly place and
challenging scenario to any surgeon
broke the sinew of his arm so that his
due to the complexities of nerve wrist was less, and his bow dropped
regeneration, nerve transfer, and the from his hand as he fell forward on
surgical techniques themselves. The his knees.”
first brachial plexus nerve transfer - Homer, The Iliad, c. 800BC
occurred in 1948. With the advent of
improved microsurgical technique,
12 West Virginia Medical Journal

2. | Scientific Article
Cold Beer.” The five terminal nerve
Figure 2. branches are the musculocutaneous,
Leonardo da Vinci’s representation of the brachial plexus.2 axillary, radial, median, and ulnar
nerves. Other nerves originate from
“The nerve branches with their
various locations on the plexus.
muscles serve the nerve chords
as soldiers serve their officers, The pertinent anatomy for
and the nerve chords serve this paper includes the roots, the
the ‘sensus communis’ as the superior trunk, the suprascapular
officers serve their captain, and
nerve, and the terminal branch
the ‘sensus communis’ serves
the soul as the captain serves his nerves. Please see figures 3 and 4
lord.” for an anatomical diagram and table
- Leonardo da Vinci, c. 1508 summarizing nerves and function.
Brachial plexus injuries usually
involve either pre-ganglionic
avulsion or post-ganglionic rupture.
pathophysiology, anatomy, and It originates from the C5-T1 spinal Avulsion occurs when the nerve root
repair has led to advances in nerve roots (ventral rami). It is is torn from the spinal cord. Rupture
the treatment options for upper further divided into three trunks, occurs when the nerve is damaged
brachial plexus trauma. six divisions (three anterior and or transected distal to the dorsal
three posterior), three cords, and root ganglion but its attachment
Anatomy finally into five terminal nerve to the spinal cord is intact. There
Understanding the anatomy of branches. Medical students keep are classifications of nerve injury
the brachial plexus is important in these components straight using from Sunderland and Seddon
order to perform a nerve transfer. the acronym “Robert Taylor Drinks beyond the scope of the review.6,7
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January/February 2010 | Vol. 106 13

3. Scientific Article |
Figure 3. been lost and what functions are
Anatomical diagram of the brachial plexus. Also shown is the spinal accessory nerve (XI). most critical to regaining the highest
quality of life can be established.
The physical exam is one of the
best diagnostic tools to formulate
the exact pattern of injury. The
patient’s strength and range of
motion should be observed and
a Tinel’s test performed.8 Serial
electromyelographs (EMG) and
CT myelograms are required prior
to brachial plexus exploration.
Typically the first EMG is performed
three months following trauma
and a second EMG is performed
five months following injury. If no
progress is identified on the EMG
or during the physical exam then
a CT myelogram is obtained and
plexus exploration performed.
Post-ganglionic rupture injuries
are amenable to grafting whereas pre-
ganglionic avulsion injuries require
nerve transfer. Pre-ganglionic root
avulsion is not amenable to direct
repair and nerve transfer remains
the best option. Some injuries avulse
or rupture 80-100% of the plexus
roots. These patients are not good
Figure 4. candidates for nerve transfer due
Summary of pertinent nerves arising from the brachial plexus, major target muscles, to the loss of the lower motor roots
and functions. typically used for transfer. Often
these are treated with nerve grafts
Important Nerves for Upper Brachial plexus Injury and reconstruction from the phrenic, intercostal, or
Nerve Major muscles innervated Important functions contra-lateral brachial plexus.8
Musculocutaneous Biceps brachii, brachialis mm. Elbow flexion Concepts of Brachial Plexus
Axillary Deltoid m. Shoulder abduction & stability Reconstruction
Suprascapular Supraspinatus m. Shoulder abduction & stability Many studies document nerve
regeneration following injury;
Radial Triceps brachii, wrist/hand extensors Elbow, wrist, & finger extension
however the absolutes regarding
Median Wrist flexors, hand muscles Wrist flexion, hand function recovery remain elusive. We know
that once the nerve begins to
Ulnar Wrist flexors, hand muscles Wrist flexion, hand function
regenerate it moves at about 1-1.5
mm daily.9 The motor endplates
Physical Exam head is forcefully distracted from the with which the nerve communicates
Supraclavicular rupture or ipsilateral shoulder.8 This manner of will eventually cease to function in
avulsion accounts for about 70% forceful separation typically results 12-18 months. If a proximal plexus
of brachial plexus injuries and in pre-ganglionic root avulsion or injury occurs, then the regenerated
among these the upper roots are post-ganglionic rupture of the upper nerve may not reach the motor
involved 70% of the time. Most of roots (C5-C6) while sparing the lower end plate in time to be effective.
these injuries occur in motorcycle roots (C7, C8, T1). By performing a Salvage of critical motor end plates
or other high speed personal detailed physical exam an operative and their corresponding muscles
transportation accidents in which the plan based on what functions have may be facilitated with the transfer
1 West Virginia Medical Journal

4. | Scientific Article
Figure 5.
Intraoperative photographs during a double Oberlin procedure showing the identification of redundant ulnar and median nerve
fascicles (left) and their coaptation to the brachialis and biceps muscles respectively (right).
of nerve fascicles from uninjured Timing of reconstruction Restoration of elbow flexion can
nerves. This nerve re-routing Just as important for optimal significantly improve the activities
essentially converts a proximal functional outcome is timing to of daily living for the patient.
nerve injury into a distal nerve surgery. Studies have shown that Restoration of shoulder
injury closer to the motor endplate. nerve transfers performed within stabilization and abduction is the
By shifting the injury closer to the 6 months post-trauma yield results second most important priority
target muscle, regeneration of the superior to transfers performed in primary reconstruction of high
proximal nerve stump can reach the after 6 months post-trauma.11 It brachial plexus injuries.9-10 The
motor endplate before degradation. is important to have the patient axillary and suprascapular nerves
This is the essence of nerve transfer. evaluated by a neurologist and may also be compromised in
The three important criteria upper extremity surgeon as soon C5-C6 injuries. The axillary and
for primary brachial plexus as possible following trauma. suprascapular nerves innervate
reconstruction are patient selection, the deltoid and the suprascapular
timing to reconstruction, and Restoration of Function muscles, respectively. These
prioritizing the restoration of function. muscles abduct and stabilize
When contemplating brachial
the shoulder, providing a solid
plexus reconstruction, one must
Patient selection platform for hand function.
have a specific plan since each
Multiple studies have shown patient’s injury pattern is inherently
that younger patients recover from different. The two most important
Nerve transfer options for
nerve transfer faster and ultimately actions which need to be restored C5-C6 brachial plexus injuries
have a better outcome. Typically in the high plexus injury are elbow The current nerve transfer used
patients under 40 years of age flexion and shoulder abduction.9 for the restoration of elbow flexion
have the best functional outcome Elbow flexion is critical to human is the Oberlin transfer which was
following nerve transfer.10 interaction with the environment and first described by Christophe Oberlin
Tobacco use and compliance its restoration is the principal goal of Paris in 1994. He described the
should also be considered. It is of brachial plexus reconstruction. transfer of a single redundant
critical that the patient adheres to an This is particularly true in C5-C6 fascicle from the ulnar nerve
occupational therapy and physical injuries where the musculocutaneous directly coapted to the biceps motor
therapy program before surgery. nerve has been compromised. fascicle.12 This transfer restores
Even if function is restored, if the The musculocutaneous nerve elbow flexion following loss of the
joints have ceased working then innervates the brachialis and musculocutaneous nerve, a branch of
the reconstruction is for naught. biceps which are the elbow flexors. the lateral cord. In 2004 he reported
January/February 2010 | Vol. 106 1

5. Scientific Article |
that 20 of 32 patients who underwent brachialis, a strong elbow flexor, description was through an anterior
the procedure recovered active has improved outcome following approach which was a difficult
motion against gravity and resistance loss of the musculocutaneous dissection for the surgeon, not
(M4).12 This procedure was validated nerve. In 2005 Oberlin reported well tolerated by the patient, and
by Leechavengvongs in Thailand 15 of 15 patients recovered M4 required an interpositional graft. The
who reported his experience with strength and MacKinnon reported transfer was essentially abandoned
26 of 32 patients who had regained 6 of 6 recovering M4 strength.14,15 for other options until 2003 when
M4 elbow flexion following the No patients from either study Leechavengvongs from Thailand
Oberlin transfer.13 In both studies exhibited motor or sensory loss described the posterior approach.18
none of the patients displayed any from the donor nerves. The addition Through a single longitudinal
sequelae from sacrificing an ulnar of the median nerve coaptation incision the anterior branch to the
nerve fascicle as a donor.12,13 has increased the success of the axillary nerve is isolated in the
Unfortunately some patients in procedure without sacrificing quadrilateral space. Subsequently
the French and Thai studies required native residual hand function.14,15 the radial nerve is dissected in the
further muscle origin transfers Two nerve transfers, the radial to triangular interval just distal to the
(Steindler Flexorplasty) to improve axillary and spinal accessory to the teres major. At this point the motor
elbow flexion. Researchers found suprascapular, are currently used nerve to the long head of the triceps is
that when the brachialis muscle was to restore shoulder stabilization and identified and coapted to the anterior
re-innervated the patient achieved abduction in upper plexus avulsions. branch of the axillary nerve restoring
better elbow flexion than biceps re- These transfers can be used
innervation to the deltoid muscle.
innervation alone.12-15 In search of a independently, but they have been The posterior approach was
procedure which would eliminate the shown to provide better results when revolutionary because the ease of
need for additional muscle transfer, performed in combination.16,17 Good dissection, no interpositional graft
Oberlin along with Susan MacKinnon outcome ( M3) has been reported was required, and it places the
in St. Louis, described the Oberlin in 86% of patient undergoing donor close to the motor endplate
double nerve transfer in 2003.14,15 In concurrent transfer to both the of the recipient.18 Additionally
this repair one redundant fascicle axillary and suprascapular nerve.16,17 the nerve transfer can improve
from the ulnar and median nerves are Transferring the radial to axillary shoulder stability and abduction
coapted directly to the motor braches nerve was originally described because it is additive with the
of the biceps and brachialis muscles. in 1948 by Alexander Lurje from spinal accessory to suprascapular
The additional re-innervation of the Russia.5 However his initial nerve transfer. Leechavengvongs
Figure 6.
Cadaveric dissection showing the spatial relationship between the radial nerve in the triangular space and the axillary nerve in the
quadrilateral space.
1 West Virginia Medical Journal

6. | Scientific Article
Figure 7. brachial plexus. Annals of Surgery. 1948
Feb.;127(2):317-26.
Summary of nerve injuries, transfer options, and restored functions for the upper plexus. 6. Seddon HJ: Three types of nerve injury.
Nerve Transfer options Brain. 1943 Dec.;66(4):237–88.
7. Sunderland S. A classification of peripheral
Injured Nerve Nerve Transfer function restored nerve injuries producing loss of function.
Musculocutaneous Median and ulnar fascicles Elbow flexion 8.
Brain. 1951 Dec.;74(4):491-516.
Terzis JK, Kostopoulos VK. The surgical
Axillary Radial fascicles Shoulder stability and abduction treatment of brachial plexus injuries in
Suprascapular Spinal accessory (XI) fascicles Shoulder stability and abduction adults. Plast Reconstr Surg. 2007
Apr.;119(4):73-92.
9. Weber R, MacKinnon S. Nerve transfers in
the upper extremity. Journal of the
reported that 7 of 7 patients achieved reported 13 of 15 patients with American Society for Surgery of the Hand.
deltoid function against gravity complete C5-C6 avulsion regained 10.
2004 Aug.;4(3):200-13.
Dvali L, Mackinnon S. Nerve repair,
(M4) with a mean of 124 degrees M4 elbow and shoulder abduction.16 grafting, and nerve transfers. Clin Plast
of shoulder abduction.19 There was This series used the older single Surg. 2003 Apr.;30(2):203-21.
Oberlin transfer and more recent 11. Terzis JK, Kostas I. Suprascapular nerve
no reported shoulder subluxation
reconstruction in 118 cases of adult
or loss of triceps function.19 experience suggests that elbow posttraumatic brachial plexus. Plast
The spinal accessory to flexion can be further improved. Reconstr Surg. 2006 Feb.;117(2):613-29.
suprascapular nerve transfer is 12. Teboul F, Oberlin C. Transfer of fascicles
from the ulnar nerve to the nerve to the
an older yet reliable option for Conclusion biceps in the treatment of upper brachial
restoration of glenohumeral stability Injury to the brachial plexus is a plexus palsy. J Bone Joint Surg Am. 2004
and shoulder abduction.8,11,20 The devastating and life altering event for
July;86(7):1485-90.
13. Leechavengvongs S, Witoonchart K, et. al.
spinal accessory nerve is a cranial the patient as well as a challenging Nerve transfer to biceps muscle using a
nerve which serves to innervate reconstructive dilemma for the part of the ulnar nerve in brachial plexus
the trapezius muscle distal in its surgeon. Recent strides have been
injury (upper arm type): a report of 32
cases. J Hand Surg Am. 1998
course. Originally this transfer made in the diagnosis, management, July;23(4):711-6.
required a large supraclavicular and treatment of upper brachial 14. Liverneaux PA, Oberlin C, et. al.
Millesi incision for access however plexus root avulsion. Nerve transfers
Preliminary results of double nerve transfer
to restore elbow flexion in upper type
recent advances in technique have have evolved into a valuable option; brachial plexus palsies. Plast Reconstr
permitted much smaller and more however, a thorough understanding Surg. 2006 Mar.;117(3):915-9.
aesthetic incisions. This transfer of clinical anatomy and timing to
15. Mackinnon SE, Novak CB, et. al. Results
of reinnervation of the biceps and
has been successful largely due to coaptation are crucial for optimal brachialis muscles with a double fascicular
its consistent anatomy, and close outcome. A combined three nerve transfer for elbow flexion. J Hand Surg Am.
proximity to the donor nerve which transfer consisting of the Double
2005 Sep.;30(5):978-85.
16. Leechavengvongs S, Witoonchart K, et. al.
negates the need for interpositional Oberlin, radial to the axillary, Combined nerve transfers for C5 and C6
grafting. Terzis reported that in 118 and the spinal accessory to the brachial plexus avulsion injury. J Hand
spinal accessory transfers outcomes suprascapular has been shown to be
Surg Am. 2006 Feb.;31(2):183-9.
17. Bertelli JA, Ghizoni MF. Reconstruction of
were good to excellent in 79% of an effective primary reconstruction C5 and C6 brachial plexus avulsion injury
patients.11 These results were echoed for adult C5-C6 injuries. by multiple nerve transfers: spinal
by Spinner who reported a good accessory to suprascapular, ulnar fascicles
to biceps branch, and triceps long or lateral
outcome in 74% of his 577 transfers.21 References head branch to axillary nerve. J Hand Surg
When considering brachial 1. Aydn A, et. al. Three-thousand-year-old Am. 2004 Jan.;29(1):131-9.
plexus reconstruction for C5-C6 written reference to a description of what 18. Witoonchart K, Leechavengvongs S, et. al.
Nerve transfer to deltoid muscle using the
root avulsions these three nerve might be the earliest brachial plexus
nerve to the long head of the triceps, part I:
injuries in the Iliad of Homer. Plast
transfers have been shown to be Reconstr Surg. 2004 Oct.;114(5):1352-3. an anatomic feasibility study. J Hand Surg
effective both individually and in 2. da Vinci, Leonardo. The brachial plexus. Am. 2003 July;28(4):628-32.
19. Leechavengvongs S, Witoonchart K, et. al.
combination. This “bundled” transfer c.1508. The Royal Collection. © 2005, Her
Majesty Queen Elizabeth II. Available Nerve transfer to deltoid muscle using the
when performed prior to six months online: http://www.universalleonardo.org/ nerve to the long head of the triceps, part
following injury in patients under 40 work.php?id =355. August 5, 2008. II: a report of 7 cases. J Hand Surg Am.
years of age has achieved excellent 3. Kennedy, Robert. On the restoration of co- 2003 July;28(4):633-8.
ordinated movements after nerve-crossing, 20. Malessy MJ, et. al. Evaluation of
results.16,17 The bundle is successful with interchange of function of the cerebral suprascapular nerve neurotization after
because it concentrates on two critical cortical centers. Philosophical Transactions nerve graft or transfer in the treatment of
areas, elbow flexion and shoulder of the Royal Society of London, Series B, brachial plexus traction lesions.
Containing Papers of a Biological
stability. Additionally it provides Character. 1901;194:127-162.
Neurosurgical Focus. 2004
similar motor to motor nerve 4. Langley JN, Anderson HK. The union of
Sep.;101(3):377-89.
different kinds of nerve fibres. J. Physiol. 21. Songcharoen P, Spinner R., et. al. Brachial
coaptation without interpositional plexus injuries in the adult. Nerve
1904 Aug.;31(5):365-91.
grafts which speeds re-education. 5. Lurje A. Concerning surgical treatment of transfers: the Siriraj Hospital experience.
A recent study from Thailand traumatic injury of the upper division of the Hand Clin. 2005 Feb.;21(1):83-9.
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