15: Nerve Transfer Techniques for Elbow Flexion in Brachial Plexus Palsy

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Procedure 15 Nerve Transfer Techniques for Elbow Flexion in Brachial Plexus Palsy

Lynda J. Yang

imageSee Video 13: Nerve Transfers for Elbow Flexion in Brachial Plexus Palsy (Ulnar Fascicle to Musculocutaneous Nerve)

Indications

image Lack of elbow flexion/supination

image Available functional donor nerve with a lesser-valued function (e.g., ulnar fascicle to flexor carpi ulnaris with normal muscle power) in close proximity with recipient nerve/muscle

image Available recipient nerve without distal injury (e.g., intact musculocutaneous nerve branch to biceps in patients with supraclavicular brachial plexus injury)

image Donor and recipient nerves ideally with agonistic functions (e.g., flexion of elbow, wrist)

Examination/Imaging

Clinical Examination

image Examine the involvement of all muscles that contribute to elbow flexion—biceps, brachialis, and brachioradialis—to determine the site of injury (e.g., nerve root versus peripheral nerve).

image Examine the active and passive range of motion at the elbow.

image Examine the integrity of the vascular supply to the arm.

image Examine the integrity of the donor nerve/muscle (e.g., flexor carpi ulnaris).

image Determine whether the biceps muscle is ruptured, because end-organ injury would preclude nerve transfer.

Surgical Anatomy

image Pertinent surgical anatomy includes the neurovascular anatomy in the medial aspect of the arm.

Positioning

image Position the patient supine with the arm extended onto a surgical arm board.

image In patients with decreased shoulder range of motion, an external positioning device can be used to place the arm in abduction and external rotation to reveal the medial aspect of the upper arm (Fig. 15-1).

image

FIGURE 15-1

Exposures

image Ulnar fascicle to musculocutaneous nerve: An incision is made along the medial arm from the pectoralis muscle insertion site to distally, with the incision overlying the path of the neurovascular bundle that lies between the biceps and triceps (see Fig. 15-1).

image Double fascicular nerve transfer for elbow flexion: The double fascicular nerve transfer for elbow flexion employs (1) the ulnar nerve fascicles innervating the flexor carpi ulnaris to the musculocutaneous branch innervating the biceps; and (2) the median nerve fascicles innervating the flexor carpi radialis to the musculocutaneous branch innervating the brachialis.

Pearls

The ulnar nerve is more medial than the median nerve. The brachial artery is adjacent to the median nerve (Fig. 15-2).

The first nerve exposed is usually the medial antebrachial cutaneous nerve that can be traced proximally to the medial cord and ulnar nerve.

The musculocutaneous nerve and its branches can be found under the biceps muscle; identifying the lateral antebrachial cutaneous nerve and tracing it proximally to expose the main trunk of the musculocutaneous nerve may facilitate exposure.

The fascicle of the ulnar nerve to the flexor carpi ulnaris usually lies in the volar radial position within the ulnar nerve.

image

FIGURE 15-2

Procedure

Step 1

image Open the biceps fascia to reveal the branch of the musculocutaneous nerve innervating the biceps muscle and transect it proximally.

Step 1 Pearls

Ensure careful identification and protection of the median nerve, ulnar nerve, and brachial artery (Fig. 15-3).

The branches of the musculocutaneous nerve to the biceps can be dissected proximally by opening the epineurium until its fascicles become physically inseparable from the parent nerve, then transected sharply to serve as the recipient nerve (Fig. 15-4).

image

FIGURE 15-3

image

FIGURE 15-4

Step 2

image Isolate the appropriate ulnar nerve fascicles for use as the donor by opening the epineurium of the ulnar nerve (see Fig. 15-4).

image The desired fascicles can be dissected proximally and distally until they are of adequate length for a tension-free coaptation with the musculocutaneous nerve. The fascicles are then transected sharply as distally as possible and coapted with the appropriate recipient nerve (see Fig. 15-4).

Step 2 Pearls

Careful intraneural dissection will reveal one or two fascicles with diffuse innervation of the distal muscles with emphasis on the flexor carpi ulnaris (usually found superficially in the ulnar nerve) using intraoperative nerve stimulation; avoid those fascicles with primary innervation to the hand intrinsic muscles.

Step 2 Pitfalls

Transecting the donor too proximally or the recipient too distally may necessitate the use of a nerve graft, which is not desirable for optimal outcome (Fig. 15-5).

image

FIGURE 15-5

Step 3

image If both the musculocutaneous branches to the biceps and brachialis are desired, in addition to the dissection for the ulnar nerve fascicles, an intraneural dissection of the median nerve is undertaken.

image Locate the branch of the musculocutaneous nerve innervating the brachialis distal to the branch to the biceps.

Step 3 Pearls

The fascicles that primarily serve to innervate the flexor carpi radialis (confirm function of fascicles with intraoperative nerve stimulation) are optimal for use as donor nerve.

Tension-free coaptation is desirable (Fig. 15-6).

image

FIGURE 15-6

Postoperative Care and Expected Outcomes

image A soft wrap or sling can be used with care to avoid pressure on the medial aspect of the arm.

image Physical therapy for range of motion can start 4 to 6 weeks postoperatively.

image Recovery of reinnervated muscle function occurs from 6 months to 3 years postoperatively.

image The expected outcome of the surgery is improved active elbow flexion.

Evidence

Bertelli JA, Florianopolis SC, Ghizoni MF, Tubarao SC. Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg [Am]. 2004;29:131-139.

This retrospective study reports the results of nerve transfer surgery on 10 adult patients at a mean of 2 years after surgery. All patients who underwent ulnar fascicle to musculocutaneous nerve transfer had recovered elbow flexion ≥ MRC 3 (with 70% ≥ MRC 4). (Level IV evidence)

Carlsen BT, Kircher MF, Spinner RJ, et al. Comparison of single versus double nerve transfers for elbow flexion after brachial plexus injury. Plast Reconstr Surg. 2011;127:269-276.

This retrospective review of patients who underwent single versus double nerve transfer for elbow flexion comprised 55 patients (23 single, 32 double). Fourteen of 21 single- and 24 of 30 double-nerve transfer patients showed MRC ≥4 after at least 1 year of follow-up. Outcomes were similar between the two groups for elbow flexion and supination strength. (Level IV evidence)

Goulet B, Boretto JG, Lazerges C, Chammas M. A comparison of intercostal and partial ulnar nerve transfers in restoring elbow flexion following upper brachial plexus injury (C5-C6 ± C7). J Hand Surg [Am]. 2010;35:1297-1303.

This retrospective study reports the results of nerve transfer surgery on 23 adult patients at a mean of 32 months after surgery. Twenty of 23 patients who underwent ulnar fascicle to musculocutaneous nerve transfer had recovered elbow flexion ≥ MRC 3. (Level IV evidence)

Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg [Am]. 2005;30:978-985.

This retrospective study reports the results of nerve transfer surgery on six adult patients at mean of 20.5 months after surgery. The patients who underwent ulnar fascicle to musculocutaneous nerve (biceps) transfer coupled with median fascicle to musculocutaneous nerve (brachialis) transfer had recovered mean elbow flexion (MRC 4+). (Level IV evidence)

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