RESUMO
Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.
Assuntos
Nervo Ulnar/transplante , Transferência de Nervo/reabilitação , Transferência de Nervo/estatística & dados numéricos , Articulação do Cotovelo , Nervo Mediano/transplante , Prontuários Médicos , Interpretação Estatística de Dados , Transferência de Nervo/métodos , Estatísticas não Paramétricas , Neuropatias do Plexo Braquial/cirurgiaRESUMO
PURPOSE: Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. METHODS: We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. RESULTS: The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. CONCLUSION: Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Nervo Mediano/transplante , Transferência de Nervo/métodos , Nervo Ulnar/transplante , Articulação do Cotovelo , Feminino , Humanos , Lactente , Masculino , Amplitude de Movimento Articular , Estudos RetrospectivosRESUMO
PURPOSE: To analyze the anatomical feasibility of transferring a motor branch nerve to the flexor carpi ulnaris (FCU) to the triceps upper medial head motor branch (UMHM) and to report the resultant outcome of the restoration of elbow extension in 5 patients with extensive brachial plexus injury. METHODS: The ulnar and radial nerves were dissected in 10 cadavers. We measured the length and diameter of the branches to the FCU and the UMHM branch and counted the axons. Then, 5 male patients, mean age 30 years, underwent FCU nerve branch transfer for reconstruction of elbow extension. Elbow flexion was restored via a median nerve branch to biceps transfer. RESULTS: Mean UMHM nerve length and diameter were 86 and 1.5 mm, respectively. Mean number of branches to the FCU muscle was 2.9. Mean FCU nerve length and diameter were 50 and 1.0 mm, respectively. Mean number of myelinated fibers was 818 and 743 for the UMHM and the longest branch to the FCU, respectively. Coaptation between nerves was possible without tension. All patients recovered functional active elbow extension at a mean follow-up of 19 months with a British Medical Research Council score of M4. After surgery, all patients retained a functional FCU with a British Medical Research Council score of M4. CONCLUSIONS: Nonselective ulnar nerve fascicles at the root of the limb might not be adequate to restore elbow extension when combined with a median nerve branch transfer for elbow flexion. A selective distal ulnar motor fascicle such as a FCU motor branch could be harvested and connected to a triceps branch to restore elbow extension. Such a nerve transfer would also allow for later transfer of the still functional FCU tendon to the digital extensors. CLINICAL RELEVANCE: For patients with extensive brachial plexus injury and a preserved medial cord, transferring a motor branch nerve to the FCU is an effective technique for the reconstruction of elbow extension. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Assuntos
Traumatismos do Braço/cirurgia , Neuropatias do Plexo Braquial/cirurgia , Músculo Esquelético/inervação , Transferência de Nervo/métodos , Nervo Radial/transplante , Nervo Ulnar/transplante , Acidentes de Trânsito , Adolescente , Adulto , Braço/inervação , Cadáver , Cotovelo/fisiologia , Estudos de Viabilidade , Humanos , Masculino , Pessoa de Meia-Idade , Nervo Radial/anatomia & histologia , Resultado do Tratamento , Nervo Ulnar/anatomia & histologiaRESUMO
The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty-five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow-up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Nervo Mediano/transplante , Nervo Ulnar/transplante , Adolescente , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: In brachial plexus injuries, when there are no available roots to use as a source for graft reconstruction, nerve transfers emerge as an elective technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. Despite the high rate of good to excellent results in adults, this technique is seldom used in children. OBJECTIVE: To evaluate the efficacy and safety of Oberlin's procedure in the surgical treatment of brachial plexus birth palsy. METHODS: Striving to restore elbow flexion, we performed Oberlin's procedure in 17 infants with brachial plexus birth palsy. After follow-up of at least 19 months, primary outcomes were the strength of elbow flexion (modified British Medical Research Council scale), hand function measured using Al-Qattan's scale, and comparative x-rays of both hands to detect altered growth. RESULTS: Good to excellent results related to biceps contraction were obtained in 14 patients (82.3%) (3/MRC3, 11/MRC4). The preoperative Al-Qattan scale score for the hand was maintained at final follow-up. Comparing the treated and normal limb, no difference was observed in hand development by x-ray. CONCLUSION: Oberlin's procedure is an effective and safe option for the surgical treatment of upper brachial plexus birth palsy.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Transferência de Nervo/métodos , Nervo Ulnar/cirurgia , Neuropatias do Plexo Braquial/diagnóstico por imagem , Cotovelo/cirurgia , Feminino , Humanos , Lactente , Masculino , Transferência de Nervo/efeitos adversos , Radiografia , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Resultado do Tratamento , Nervo Ulnar/diagnóstico por imagem , Nervo Ulnar/fisiologia , Nervo Ulnar/transplanteRESUMO
BACKGROUND: Nerve transfers or graft repairs in upper brachial plexus palsies are 2 available options for elbow flexion recovery. OBJECTIVE: To assess outcomes of biceps muscle strength when treated either by grafts or nerve transfer. METHODS: A standard supraclavicular approach was performed in all patients. When roots were available, grafts were used directed to proximal targets. Otherwise, a distal ulnar nerve fascicle was transferred to the biceps branch. Elbow flexion strength was measured with a dynamometer, and an index comparing the healthy arm and the operated-on side was developed. Statistical analysis to compare both techniques was performed. RESULTS: Thirty-five patients (34 men) were included in this series. Mean age was 28.7 years (standard deviation, 8.7). Twenty-two patients (62.8%) presented with a C5-C6 injury, whereas 13 patients (37.2%) had a C5-C6-C7 lesion. Seventeen patients received reconstruction with grafts, and 18 patients were treated with a nerve transfer from the ulnar nerve to the biceps. The trauma to surgery interval (mean, 7.6 months in both groups), strength in the healthy arm, and follow-up duration were not statistically different. On the British Medical Research Council muscle strength scale, 8 of 17 (47%) patients with a graft achieved ≥ M3 biceps flexion postoperatively, vs 16 of 18 (88%) post nerve transfers (P = .024). This difference persisted when a muscle strength index assessing improvement relative to the healthy limb was used (P = .031). CONCLUSION: The results obtained from ulnar nerve fascicle transfer to the biceps branch were superior to those achieved through reconstruction with grafts.
Assuntos
Plexo Braquial/lesões , Plexo Braquial/cirurgia , Músculo Esquelético/inervação , Transferência de Nervo/métodos , Recuperação de Função Fisiológica , Nervo Ulnar/transplante , Adulto , Braço , Feminino , Humanos , Masculino , Força Muscular , Músculo Esquelético/fisiologia , Estudos RetrospectivosRESUMO
BACKGROUND AND IMPORTANCE: Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. CLINICAL PRESENTATION: Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. CONCLUSION: The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.
Assuntos
Neuropatias do Plexo Braquial/cirurgia , Músculo Esquelético/inervação , Transferência de Nervo/métodos , Nervo Ulnar/transplante , Acidentes de Trânsito , Adulto , Braço/inervação , Cotovelo/fisiologia , Humanos , Masculino , Músculo Esquelético/cirurgia , Adulto JovemRESUMO
PURPOSE: Vascularized nerve grafts are indicated for the repair of large nerve defects. In brachial plexus injuries, the poor prognosis for functional hand reconstruction when the lower roots are avulsed makes the ulnar nerve a potential donor for vascularized nerve grafts. We report on the results we obtained with reconstruction of elbow flexion using long pedicled ulnar nerve grafts that connected the C5 root to the musculocutaneous nerve. METHODS: We prospectively studied 8 young adults with complete brachial plexus palsy with avulsion of the lower roots, who had surgical repair an average of 4.6 months after trauma. Pedicled ulnar nerve grafts, averaging 30 cm long, connected the C5 root to the musculocutaneous nerve. In order to rescue misdirected axons that could have regenerated into the cutaneous branch of the musculocutaneous nerve, we transferred this branch to the motor branch of the extensor carpi radialis brevis muscle. Outcomes for all 8 patients were assessed an average of 26.7 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale. RESULTS: None of the patients recovered elbow flexion or wrist extension greater than M2. CONCLUSIONS: In brachial plexus injuries, reconstruction of elbow flexion using a long, pedicled, vascularized nerve graft produces unsatisfactory results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Assuntos
Plexo Braquial/lesões , Microcirurgia/métodos , Nervo Musculocutâneo/cirurgia , Transferência de Nervo/métodos , Paresia/cirurgia , Raízes Nervosas Espinhais/lesões , Raízes Nervosas Espinhais/cirurgia , Retalhos Cirúrgicos/irrigação sanguínea , Retalhos Cirúrgicos/inervação , Nervo Ulnar/transplante , Adulto , Cotovelo/inervação , Feminino , Seguimentos , Humanos , Masculino , Regeneração Nervosa/fisiologia , Cuidados Pós-Operatórios/métodos , Estudos Prospectivos , Amplitude de Movimento Articular/fisiologia , Coleta de Tecidos e Órgãos/métodos , Falha de Tratamento , Adulto JovemRESUMO
OBJECTIVES: In the clinical set, autologus nerve grafts are the current option for reconstruction of nerve tissue losses. The length of the nerve graft has been suggested to affect outcomes. Experiments were performed in the rat in order to test this assumption and to detect a possible mechanism to explain differences in recovery. METHODS: The rat median nerve was repaired by ulnar nerve grafts of different lengths. Rats were evaluated for 12 months by behavioural assessment and histological studies, including ATPase myofibrillary histochemistry and retrograde neuronal labelling. RESULTS: It was demonstrated that graft length interferes in behavioural functional recovery that here correlates to muscle weight recovery. Short nerve grafts recovered faster and better. Reinnervation was not specific either at the trunk level or in the muscle itself. The normal mosaic pattern of Type I muscle fibres was never restored and their number remained largely augmented. An increment in the number of motor fibres was observed after the nerve grafting in a predominantly sensory branch in all groups. This increment was more pronounced in the long graft group. In the postoperative period, about a 20% reduction in the number of misdirected motor fibres occurred in the short nerve graft group only. CONCLUSION: Variation in the length of nerve grafts interferes in behavioural recovery and increases motor fibres misdirection. Early recovery onset was related to a better outcome, which occurs in the short graft group.
Assuntos
Nervo Mediano/cirurgia , Músculo Esquelético/fisiologia , Transferência de Nervo/métodos , Recuperação de Função Fisiológica/fisiologia , Transplante Autólogo/métodos , Nervo Ulnar/transplante , Adenosina Trifosfatases/metabolismo , Análise de Variância , Animais , Células do Corno Anterior/metabolismo , Comportamento Animal , Benzofuranos/metabolismo , Feminino , Força da Mão/fisiologia , Histocitoquímica/métodos , Nervo Mediano/fisiopatologia , Modelos Animais , Músculo Esquelético/anatomia & histologia , Músculo Esquelético/inervação , Tamanho do Órgão/fisiologia , Desempenho Psicomotor/fisiologia , Ratos , Ratos Sprague-Dawley , Fatores de TempoRESUMO
The repair of large peripheral nerve defects is not always possible, especially when the proximal stump is not available. In these cases, end-to-side nerve anastomosis has been proposed. In the present experiment, using the terminal branches of the rat brachial plexus, the authors studied behavioral responses after end-to-side nerve anastomoses using fibrin glue, 3 and 6 months after surgery. Rats were evaluated by results of a grasping test, a capsaicin test and a hot-plate test. The collected data demonstrated that there was no functional motor or sensory reinnervation after the end-to-side nerve anastomoses. The conjunctive layers of the peripheral nerve thus represented an effective barrier to reinnervation.
Assuntos
Axônios/fisiologia , Nervo Mediano/fisiologia , Regeneração Nervosa/fisiologia , Nervo Ulnar/transplante , Anastomose Cirúrgica/métodos , Animais , Feminino , Adesivo Tecidual de Fibrina , Nervo Mediano/cirurgia , Ratos , Ratos Wistar , Adesivos Teciduais , Nervo Ulnar/fisiologiaRESUMO
Se presenta el caso de un paciente que ha sufrido la sección completa del Plexo Braquial izquierdo como resultado de una agresión con arma punzo cortante a nivel de la región supraclavicular. Para efectuar la reparación quirúrgica, usamos como injerto el nervio Cubital del mismo lado de la lesión. En vista de los sorprendentes resultados obtenidos, presentamos el caso para su conocimiento y evaluación.
Assuntos
Humanos , Masculino , Adolescente , Plexo Braquial/patologia , Plexo Braquial/cirurgia , Nervo Ulnar/cirurgia , Nervo Ulnar/transplanteRESUMO
The most serious disability from which patients with leprosy suffer is sensory