Correlation of compound muscle action potential generated by donor nerves with the recovery of elbow flexion in Oberlin transfer in brachial plexus injury

ABSTRACT

Objective: To study the correlation of compound muscle action potential of donor nerves with the recovery of elbow flexion in Oberlin transfer in brachial plexus injury. Introduction: Distal nerve transfer using motor fascicle of ulnar or median nerve to restore elbow flexion is a part of reconstructive surgery after upper brachial plexus injury, first described by Oberlin et al. However, one of the most critical influences on functional outcome is number of functioning motor axons in donor fascicle which is reflected by its compound muscle action potential. We studied whether nerve transfers with donor nerves showing higher amplitudes will yield better reinnervation of muscle and therefore better function as estimated by clinical examination. Methods: We prospectively studied 30 cases of upper brachial plexus injury, of which were treated with Oberlin transfer using ulnar or median or both nerves. The prerequisites were no elbow flexion and hand and wrist flexors showing the power of more than Medical research Council MRC Grade 4. Donor nerves selected either ulnar or median having CMAP >4 mv in our electrophysiology laboratory during nerve conduction study. Patients were followed up for 1 year and assessed clinically for restoration of elbow flexion, weight tolerance. Results: A total of 30 patients of Oberlin transfer were evaluated for improvement power of biceps and elbow flexion. (MRC) grading was done at 1 year. Twenty-seven patients had a good result (MRC grade ≥3), i.e., 90% of patients. Based on the MRC grades, we categorised the patients into two groups as follows: Group A and Group B. Group A included patients with MRC Grade 4–5 and Group B included Grades 3–3.5. We tried to establish a correlation between CMAP and MRC scores by comparison of MRC grade patients for their pre CMAPs which revealed a statistically significant higher CMAPs between the groups. (Mann–Whitney U-test, P = 0.028). This indicates the association of higher pre-CMAPs with higher MRC grades. Conclusion: We conclude that higher the compound muscle action potential of donor nerves, better the recovery of elbow flexion in Oberlin transfer in brachial plexus injury.

KEY WORDS

CMAP of donor's nerves - elbow flexion - Oberlin transfer

• REFERENCES

• 1 Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. et al. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: Anatomical study and report of four cases. J Hand Surg Am 1994; 19: 232-7
• 2 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: 978-85
• 3 Liverneaux PA, Diaz LC, Beaulieu JY, Durand S, Oberlin C. Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies. Plast Reconstr Surg 2006; 117: 915-9
• 4 Lee JY, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Factors affecting outcome of triceps motor branch transfer for isolated axillary nerve injury. J Hand Surg Am 2012; 37: 2350-6
• 5 Verdú E, Ceballos D, Vilches JJ, Navarro X. Influence of aging on peripheral nerve function and regeneration. J Peripher Nerv Syst 2000; 5: 191-208
• 6 El-Gammal TA, El-Sayed A, Kotb MM. Surgical treatment of brachial plexus traction injuries in children, excluding obstetric palsy. Microsurgery 2003; 23: 14-7
• 7 Sedain G, Sharma MS, Sharma BS, Mahapatra AK. Outcome after delayed oberlin transfer in brachial plexus injury. Neurosurgery 2011; 69: 822-7
• 8 Ricardo M. Surgical treatment of brachial plexus injuries in adults. Int Orthop 2005; 29: 351-4
• 9 Bentolila V, Nizard R, Bizot P, Sedel L. Complete traumatic brachial plexus palsy. Treatment and outcome after repair. J Bone Joint Surg Am 1999; 81: 20-8
• 10 Wood MB, Murray PM. Heterotopic nerve transfers: Recent trends with expanding indication. J Hand Surg Am 2007; 32: 397-408
• 11 Kakinoki R, Ikeguchi R, Dunkan SF, Nakayama K, Matsumoto T, Ohta S. et al. Comparison between partial ulnar and intercostal nerve transfers for reconstructing elbow flexion in patients with upper brachial plexus injuries. J Brachial Plex Peripher Nerve Inj 2010; 5: 4
• 12 O'Shea K, Feinberg JH, Wolfe SW. Imaging and electrodiagnostic work-up of acute adult brachial plexus injuries. J Hand Surg Eur Vol 2011; 36: 747-59
• 13 Wilbourn AJ. Nerve conduction studies. Types, components, abnormalities, and value in localization. Neurol Clin 2002; 20: 305-38 v
• 14 Thatte MR, Agashe M, Rathod C, Lad P, Mehta R. An approach to the supraclavicular and infraclavicular aspects of the brachial plexus. Tech Hand Up Extrem Surg 2011; 15: 188-97
• 15 Bhandari PS, Deb P. Fascicular selection for nerve transfers: The role of the nerve stimulator when restoring elbow flexion in brachial plexus injuries. J Hand Surg Am 2011; 36: 2002-9
• 16 Suzuki O, Sungawa T, Yokota K. Use of quantitive intra-operative electrodiagnosis during partial ulnar nerve transfer to restore elbow flexion. J Bone Joint Surg Br 2011; 93-B: 364
• 17 Teboul F, Kakkar R, Ameur N, Beaulieu JY, Oberlin C. Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy. J Bone Joint Surg Am 2004; 86-A: 1485-90
• 18 Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Ketmalasiri W. Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): A report of 32 cases. J Hand Surg Am 1998; 23: 711-6
• 19 Schreiber JJ, Feinberg JH, Byun DJ, Lee SK, Wolfe SW. Preoperative donor nerve electromyography as a predictor of nerve transfer outcomes. J Hand Surg Am 2014; 39: 42-9