Nerve Transfers

Published on 08/03/2015 by admin

Filed under Neurosurgery

Last modified 08/03/2015

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Chapter 24 Nerve Transfers

Intercostal Nerves to Musculocutaneous Nerve

This transfer is done to neurotize the MCN.

The procedure provides useful biceps and brachialis function in about 40% to 50% of cases, depending on the series and the nature of the patients selected for the procedure.

Some controversy exists over which intercostal nerves to use to maximize motor axon outflow, as well as over the level at which they should be sectioned. We prefer to use the third, fourth, fifth, and sometimes sixth intercostal nerves and usually section them at the anterior axillary line.

The incision needs to be combined with one made to expose the plexus at the cord-to-nerve level in the axilla.

The intercostal nerves are found under the inferior surface of their respective ribs, below the intercostal vessels, in the neurovascular plane. With upward retraction on the rib, the nerve can be identified, encircled by a Vasaloop, and then dissected away from the intercostal artery and vein.

In women, the superficial branch of the T4 intercostal nerve can be spared and only the deep (motor or muscular) branch used. This preserves sensation on and around the nipple.

We dissect out lengths of 4 or 5 inches, extending from the posterior axillary line.

The intercostal nerves are sectioned anteriorly at the level of the anterior axillary line and brought back to be tunneled through axillary fat to reach the axillary level of the plexus.

They are then sewn together directly to the MCN, which has been split away from the lateral cord contribution to the median nerve, or to the axillary nerve.

Care must be taken not to lacerate the pleura. If this is done, it is repaired with 4-0 silk on a fine needle.

It is sometimes useful to harvest a small piece of pectoral or intercostal muscle to be sewn in place as a stent or stamp for closure of the hole.