Effectiveness of intercostal nerves in restoration of elbow flexion in devastating brachial plexus injuries

Abstract

In extensive lesions with root avulsions, intercostal nerves provide the source of motor axons to reanimate the elbow flexors. In long standing cases, nerve transfers are no longer effective. These patients can be rehabilitated with free functioning muscle transfers innervated by the intercostals nerves. Between September 2003 and February 2006, 48 patients with devastating brachial plexus injuries underwent intercostal nerve transfers. In 22 patients with complete palsy (C5 to T1) three intercostal nerves (3^rd,4^th & 5^th) were directly sutured to the musculocutaneous nerve. Sixteen patients had C5, C6 and C7 injuries. In 12 of these patients all the three roots were avulsed. In the remaining four, C7 spinal nerve was adhered to the scar tissue and was treated by microneurolysis. In all patients three intercostal nerves were directly coapted with the musculocutaneous nerve. Ten patients, presenting one or more years after the injury underwent free functioning muscle transfer using gracilis muscle motored by two or three intercostal nerves. Results of nerve transfers were better in the partial injury group (16 patients) with 7 patients regaining MRC grade 4, and 5 patients MRC grade 3. Four patients could achieve only M2 grade. In the total group (22 patients) only four could restore MRC grade 4 function. Eight patients attained MRC grade 3 and four patients MRC grade 2. Six patients could not restore elbow flexion. In the late group (10 patients) free functioning muscle transfer restored MRC grade 4 elbow flexion in 1 patient and MRC grade 3 function in another 5 patients. In the remaining 4 patients muscle transfer was not successful. We conclude that direct coaptation of intercostal nerves to the musculocutaneous nerve is a viable option to restore elbow flexion in total plexus injuries. Intercostal nerves are also suitable motor donors for free functioning muscle transfers.

Keywords

brachial plexus injury - elbow flexion - intercostal nerve transfer

• References

• 1 Waikakul S, Wongtragul S, Vanadurongwan V. Restoration of elbow flexion in brachial plexus avulsion injury. Comparing spinal accessory nerve transfer with intercostal nerve transfer. J Hand Surg 24 A 1999; 571-577
• 2 Songcharoen P. Brachial plexus injury in Thailand: a report of 520 cases. Microsurgery 16 1995; 35-39
• 3 Ruch DS, Friedman A, Nunley JA. The restoration of elbow flexion with intercostal nerve transfers. Clin orthop 314 1995; 95-103
• 4 Malessy MJ, Thomeer RT. Evaluation of intercostals to musculocutaneous nerve transfer in reconstructive brachial plexus injury. J Neurosurg 88 1998; 266-271
• 5 El- Gammal TA, Fathi NA. Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfer. J Reconstr Microsurg 18 2002; 7-15
• 6 Yoeman P, Seddon H. Brachial plexus injuries treatment of the flail arm. J Bone Joint Surg 43 B 1961; 493-500
• 7 Seddon HJ. Nerve grafting. J Bone Joint Surg 45B 1963; 447-461
• 8 Kawai H, Kawabata H, Masada Ketal. Nerve repairs for traumatic brachial plexus palsy with root avulsion. Clin Orthop 237 1988; 75-86
• 9 Narakas A. Brachial plexus surgery. Orthop Clin North Am 12 1981; 303-323
• 10 Sedel L. The results of surgical repair of brachial plexus injuries. J Bone Joint Surg 64B 1982; 54-66
• 11 Millesi H. Brachial plexus injuries. Management and results. Clin Plast Surg 11 1984; 115-120
• 12 Minami M, Ishii S. Satisfactory elbow flexion in complete (preganglionic) brachial plexus injuries produced by suture of third and fourth intercostal nerves to musculocutaneous nerve. J Hand Surg 12A 1987; 1114-1118
• 13 Friedman AH, Nunley JA, Goldner RD. et al Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 72 1990; 59-64
• 14 Kline DG, Hudson AR. Nerve injuries. Operative results for major nerve injuries, entrapments, and tumors. 1995. WB Sauders; Philadelphia:
• 15 Kawabata H, Shibata T, Matsui Y, Yasui N. Use of intercostal nerves for neurotization of the musculocutaneous nerve in injury with birth related brachial plexus palsy. J Neurosurg 94 2001; 386-391
• 16 Krakauer JD, Woud MB. Rochester. Intercostal nerve transfer for brachial plexopathy. J Hand Surg 19A 1994; 829-835
• 17 Totosy De Zepetnek JE, Zung HV, Erdebil S, Gordon T. Innervation ratio is an important determinant of force in normal and reinnervated rat tibialis anterior muscle. J Neurophysiol 67 1992; 1385-1392
• 18 Chuang DC, Yeh MC, Wei FC. Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuriesevaluation of 66 patients. J Hand Surg 17 A 1992; 822-828
• 19 Nagano A, Truyana N, Ochiai N, Hara T, Takahashi M. Direct nerve crossing with the intercostal nerve to treat avulsion injuries of the brachial plexus. J Hand Surg 14A 1989; 980-985
• 20 Chiarapattanakam P, Leechavengvangs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. Anatomy and internal topography of the musculocutaneous nerve. The nerves to the biceps and brachialis muscle. J Hand Surg 23A 1998; 250-255
• 21 Doi K, Muramatsu K, Hattori Y, Otsuka K, Tan SH, Nanda V, Watanabe M. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long term results. J Bone Joint Surg 82A 2000; 652-666
• 22 Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Double free muscle transfer to restore prehension following complete brachial plexus avulsion. J Hand Surg 20A 1995; 408-414
• 23 Doi K. Management of total paralysis of the brachial plexus by double free muscle transfer technique. J Hand Surg 33B 2008; 240-251