Wen-Dong Xu

Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury.

&NA; Phrenic nerve transfer has been widely used in treating brachial plexus avulsion injury. However, the present method crosses the thoracic part of the phrenic nerve, and nerve graft is needed, resulting in a long period of regeneration and partly irreversible muscle atrophy. We present our early experience of using video‐assisted thoracic surgery to harvest a full length of phrenic nerve for transfer. Fifteen patients (mean age, 28 years) were treated. The thoracic part of the phrenic nerve was freed by means of video‐assisted thoracic surgery and taken out of the thoracic cavity, and a full‐length phrenic nerve was transferred to the musculocutaneous nerve to recover elbow flexion. The patients were followed. Another 29 patients with long‐term follow‐up who underwent traditional cervical phrenic nerve to musculocutaneous nerve transfer in our institute between 1994 and 1997 were selected. The period of newborn potential appearing in the biceps and the period for biceps to achieve M3 between two groups were compared. The operation was safe and no complications occurred. The additional length of phrenic nerve was 12.3 ± 4.5 cm. Eleven patients received sufficient follow‐up. Eight patients achieved biceps recovery to M3 (elbow flexion against gravity), and mean time was 198.8 ± 36.0 days, much earlier than that of the traditional method (p < 0.01). Pulmonary function recovered to the preoperative level 9 months after operation. This new method is safe and minimally invasive. The result of full‐length phrenic nerve transfer is much better than that of the traditional method. It obviously shortens the time required for nerve reinnervation, and offers a promising method for patients who have had a long interval from injury to operation and for forearm muscle reconstruction by phrenic nerve transferred to the median nerve or combined with free‐muscle transfer.

Phrenic Nerve Transfer for Elbow Flexion and Intercostal Nerve Transfer for Elbow Extension

PURPOSE To explore long-term recovery of elbow flexion and extension after transferring the phrenic nerve and intercostal nerves, respectively, in adults with global brachial plexus avulsion injuries. METHODS Seven adults with global brachial plexus avulsion injuries had the phrenic nerve transferred to the musculocutaneous nerve (or to the anterior division of upper trunk) and intercostal nerves transferred to the triceps branch of the radial nerve at our hospital 7 to 12 years ago. The results of elbow motor strength testing using the Medical Research Council grading scale, and electrodiagnostic findings using electromyogram examinations, were studied retrospectively. Pulmonary function tests were also performed at final visits. RESULTS Functional elbow flexion was obtained in most of the 7 cases (M2, 1; M3, 3; M4, 2; and M5, 1) but elbow extension was absent or insufficient in all subjects (M0, 1; M1, 3; and M2, 3). Electrical results showed successful biceps reinnervation in 6 patients and successful triceps reinnervation in 5. No patient experienced breathing problems, and pulmonary function results were within normal range. CONCLUSIONS In the long term, after brachial plexus avulsion injury in most patients who underwent both phrenic nerve and intercostal nerve transfer to achieve elbow flexion and extension eventually obtained satisfactory elbow flexion but poor elbow extension. We recommend against transferring the intercostal nerves to the triceps branch of radial nerve in conjunction with primary phrenic to musculocutaneous nerve transfer. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Operative versus nonoperative treatment in the management of midshaft clavicular fractures: a meta-analysis of randomized controlled trials

BACKGROUND There is no consensus on the effects of operative versus nonoperative treatment on the outcomes of midshaft clavicular fractures in adults. We conducted a meta-analysis of randomized clinical studies. MATERIALS AND METHODS We searched the literature and included studies that investigated the effects of operative versus nonoperative intervention on the outcome of midshaft clavicular fractures. Patient data were pooled by use of standard meta-analytic approaches. For the continuous variables, the weighted mean difference was used. For dichotomous data, the relative risk was calculated. RESULTS Seven studies reported in 8 publications were eligible for data extraction. The pooled analyses showed that, compared with nonoperative treatment, operative treatment led to significantly lower incidences of nonunion and fewer symptomatic malunions. Subgroup analysis indicated that these advantages could be ascribed to plate fixation. Furthermore, surgery with plates resulted in significantly fewer complications. Patients undergoing surgery had better Disabilities of the Arm, Shoulder and Hand and Constant scores and lower dissatisfaction with their appearance. CONCLUSION In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment. Surgery with plates results in lower incidences of nonunion, fewer total complications, and fewer symptomatic malunions compared with nonoperative treatment.

Reorganization in motor cortex after brachial plexus avulsion injury and repair with the contralateral C7 root transfer in rats.

The purpose of our study was to establish the profile of cortical reorganization in whole BPAI on rats and evaluate changes of cortical reorganization after repair of the median nerve with the contralateral C7 root transfer. Forty adult SD rats underwent whole roots avulsion of left brachial plexus, among them 20 received contralateral C7 root transfer to the injured median nerve. Intracortical microstimulation was performed in primary motor cortex (M1) at intervals of 3, 5, 7, and 10 months, postoperatively. The maps of motor cortical responses were constructed. Five normal rats were used as the control. Results showed that stimulating right M1 elicited motion of left vibrissae, submaxilla, neck, back, and left hindlimb after left BPAI, among them neck representation area replaced the forelimb area throughout the reorganization process. The left forelimb representation area was found in the left motor cortex 5 months after the contralateral C7 root transfer and existed in both motor cortexes at 7th postoperative month. The left forelimb representation area was detected only in right motor cortex at 10th month, postoperatively. In conclusions, after the contralateral C7 root transfer for repair of the median nerve in BPAI, the cortical reorganization occurred in a time‐dependent reorganization. The findings from this study demonstrate that brain involves in the functional recovery after BPAI and repair with nerve transfer and suggest that efforts to improve the results from nerve repair should address the peripheral nerve as well as the brain.

Long-term ongoing cortical remodeling after contralateral C-7 nerve transfer

OBJECT Contralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer. METHODS In this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional MRI studies were used for the investigation of long-term cerebral plasticity. RESULTS The neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period; at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation. CONCLUSIONS The authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.

Partial Ipsilateral C7 Transfer to the Upper Trunk for C5-C6 Avulsion of the Brachial Plexus

BACKGROUND Ipsilateral whole C7 root transfer has been reported in treating C5-C6 avulsion. To minimize donor deficits, partial ipsilateral C7 (PIC7) transfer was developed. OBJECTIVE To investigate the long-term results of PIC7 transfer to the upper trunk in treating C5-C6 avulsion of the brachial plexus. METHODS We prospectively studied 8 young adults with C5-C6 avulsion. Five patients (group A) who also had spinal accessory nerve (SAN) injury underwent PIC7 transfer to the upper trunk. The other 3 patients (group B) without SAN injury underwent a combination of PIC7 to the upper trunk and the SAN to the suprascapular nerve (SSN). Postsurgical evaluations including donor deficits, functional recovery, and co-contraction of the muscles were performed 1 week later and then at intervals of 3 months. RESULTS After a mean period of 39.2 months, all subjects were found to have gained elbow flexion of 110 to 150° with muscle strength of M4-5. The patients in group B achieved external rotation of 60 to 70° at M3-4, and 2 achieved shoulder abductions approaching 180° at M4. The patients in group A showed no active external rotation and shoulder abduction of 25 to 50° at M2-3. The temporary deficits caused by PIC7 transfer disappeared in all subjects within the first 3 months. Co-contraction of the latissimus dorsi against the deltoid was recorded in group A but not in group B. CONCLUSION PIC7 transfer, when combined with SAN transfer to SSN as a novel approach, is a safe, easy, and efficacious surgical procedure for patients with simple C5-C6 avulsion.

Hand prehension recovery after brachial plexus avulsion injury by performing a full-length phrenic nerve transfer via endoscopic thoracic surgery

OBJECT The functional recovery of hand prehension after complete brachial plexus avulsion injury (BPAI) remains an unsolved problem. The authors conducted a prospective study to elucidate a new method of resolving this injury. METHODS Three patients with BPAI underwent a new procedure during which the full-length phrenic nerve was transferred to the medial root of the median nerve via endoscopic thoracic surgery support. All 3 patients were followed up for a postoperative period of > 3 years. RESULTS The power of the palmaris longus, flexor pollicis longus, and the flexor digitorum muscles of all 4 fingers reached Grade 3-4/5, and no symptoms of respiratory insufficiency occurred. CONCLUSIONS Neurotization of the phrenic nerve to the medial root of the median nerve via endoscopic thoracic surgery is a feasible means of early hand prehension recovery after complete BPAI.

Changes of inter-hemispheric functional connectivity between motor cortices after brachial plexuses injury: a resting-state fMRI study

OBJECT The aim of this study is to explore the changes of inter-hemispheric functional connectivity in patients with unilateral brachial plexus injury. METHODS Nine patients with five roots of unilateral brachial plexus avulsion injury and 11 healthy controls were recruited in this study. Resting-state functional connectivity magnetic resonance image was used to study the differences of inter-hemispheric functional connectivity between patients and healthy controls. Four areas were defined as regions of interest (ROI): the two primary motor areas (M1 areas) and two supplementary motor areas (SMAs) in the two hemispheres activated when the healthy controls performed unilateral hand grasping movement of the two hands, respectively. Functional connectivity maps were generated by correlating the regional time course of each ROI with that of every voxel in the whole brain. Then, functional connectivity was calculated by correlating the functional magnetic resonance image signal time courses of every two ROIs. RESULTS Resting-state inter-hemispheric functional connectivity of the primary motor areas was reduced following brachial plexus avulsion injury. The correlation coefficients of the SMAs showed no difference between the brachial plexus patients and healthy volunteers. CONCLUSIONS Our results indicate that brachial plexus injury decreases resting-state inter-hemispheric functional connectivity of the two primary motor areas. These results provide new insight into functional reorganization of the cerebral cortex after brachial plexus injury.

Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach

The upper brachial plexus injury leads to paralysis of muscles innervated by C5 and C6 nerve roots. In this report, we present our experience on the use of the combined nerve transfers for reconstruction of the upper brachial plexus injury. Nine male patients with the upper brachial plexus injury were treated with combined nerve transfers. The time interval between injury and surgery ranged from 3 to 11 months (average, 7 months). The combined nerve transfers include fascicles of the ulnar nerve and/or the median nerve transfer to the biceps and/or the brachialis motor branch, and the spinal accessory nerve (SAN) to the suprascapular nerve (SSN) and triceps branches to the axillary nerve through a posterior approach. At an average of 33 months of follow‐up, all patients recovered the full range of the elbow flexion. Six out of nine patients were able to perform the normal range of shoulder abduction with the strength degraded to M3 or M4. These results showed that the technique of the combined nerve transfers, specifically the SAN to the SSN and triceps branches to the axillary nerve through a posterior approach, may be a valuable alternative in the repair of the upper brachial plexus injury. Further evaluations of this technique are necessary.

Contralateral C7 nerve root transfer in treatment of cerebral palsy in a child: Case report

A 4‐year‐old girl who sustained the hemiplegic cerebral palsy and subsequent spasticity in the left upper extremity underwent the C7 nerve root rhizotomy and the contralateral C7 nerve root transfer to the ipsilateral middle trunk of brachial plexus through an interpositional sural nerve graft. In a 2‐year follow‐up, the results showed a reduction in spasticity and an improvement in extension power of the elbow, the wrist, and the second to fifth fingers. Scores from both Quality of Upper Extremity Skills Test and Modified Ashworth Scale tests had been significantly improved during follow‐up. The outcomes from this case provided the evidence that combined the C7 nerve root rhizotomy and contralateral healthy C7 nerve root transfer to the ipsilateral middle trunk of brachial plexus not only partially released flexional spasticity but also strengthened extension power of the spastic upper extremity in children with the cerebral palsy.