Spinal accessory to suprascapular nerve transfer in brachial plexus injury: outcomes of anterior vs. posterior approach to the suprascapular nerve at associated ipsilateral spinal accessory nerve injury
Keywords:brachial plexus injury, suprascapular nerve, spinal accessory nerve, nerve transfer
Objective: The spinal accessory nerve (Acc) is susceptible to trauma in at least 6% of cases of brachial plexus injury (BPI). The impaired Acc function disables its utilization for transfer to the suprascapular nerve (SS). The selection of approach to SS is highly dependant on the anatomy of BPI. The purpose of this study was to determine the incidence of the anterior-posterior approach of Acc to SS transfer in BPI and associated functional outcomes.
Methods. Twenty nine patients with BP/Acc associated injury were included. Ten patients underwent the transfer of Acc to SS by the anterior approach (AA), 19 patients – by the posterior approach (PA). Nine nerve transfers through AA and one nerve transfer through PA required the interposition of an autologous nerve graft. The functioning of the supra-/infraspinatus muscle was evaluated at 9 and 15mos. on the basis of the MRC and the external rotation (ER) range. ER more than +400 beyond the sagittal plane was regarded as effective recovery of function.
Results. Impaired function (M3 or lower on MRC) of the lower trapezius muscle was associated with preserved anatomy of the SS in the supraclavicular region in 9 out of 10 cases. Eighteen patients (62%) recovered to M3 and higher (shoulder stability), 11of these (38%) showed recovery to M4-M5. Five of all patients recovered to M4-M5 and were able to produce ER within the effective ROM (+400-600 of ER). After the AA to the SS, shoulder stability was restored in 60% of cases (M4-M5 in 30%). After the PA to the SS, shoulder stability was restored in 74% of cases (M4-M5 in 42%). Only non-complete BPI showed effective recovery of power and function in terms of less than 6 mos. after injury. PA to SS with no graft provided shoulder stability in 72% of cases, AA to the SS and the graft interposition ensured shoulder stability in 50% of cases.
Conclusions. The incidence of AA to the SS was 35%, PA – 65%; preserved anatomy of the SS in supraclavicular region was associated with an increased risk of trapezius muscle dysfunction; the PA to SS and consecutive direct end-to-end transfer of Acc showed better results compared to other combinations of nerve transfers in providing shoulder stability.
Domeshek LF, Novak CB, Patterson JMM, et al. Nerve Transfers-A Paradigm Shift in the Reconstructive Ladder. Plast Reconstr Surg Glob. Published online June 25, 2019. doi:10.1097/GOX.0000000000002290;
Moore AM. Nerve Transfers to Restore upper Extremity Function: A Paradigm Shift. Front Neurol. Published online March 31, 2014. doi:10.3389/fneur.2014.00040;
Maurya S, Renganathan G, R V, Bharti R. Outcomes of Shoulder Functions in Spinal Accessory to Suprascapular Nerve Transfer in Brachial Plexus Injury: A Comparison between Anterior and Posterior Approach. Indian J Plast Surg. 2021;54(2):152-156;
Bahm J, Noaman H, Becker M. The dorsal approach to the suprascapular nerve in neuromuscular reanimation for obstetric brachial plexus lesions. Plast Reconstr Surg. 2005;115(1):240-244;
Colbert SH, Mackinnon S. Posterior approach for double nerve transfer for restoration of shoulder function in upper brachial plexus palsy. Hand (N Y). 2006;1(2):71-77;
Coene LN. Mechanisms of brachial plexus lesions. Clin Neurol Neurosurg. 1993;95 Suppl:S24-S29;
Bertelli JA, Ghizoni MF. Combined injury of the accessory nerve and brachial plexus. Neurosurgery. 2011;68(2):390-396;
Kim DH, Cho YJ, Tiel RL, Kline DG. Surgical outcomes of 111 spinal accessory nerve injuries. Neurosurgery. 2003;53(5):1106-1103;
Porter P, Fernandez GN. Stretch-induced spinal accessory nerve palsy: a case report. J Shoulder Elbow Surg. 2001;10(1):92-94;
Flores LP, Socolovsky M. Phrenic Nerve Transfer for Reconstruction of Elbow Extension in Severe Brachial Plexus Injuries. J Reconstr Microsurg. 2016;32(7):546-550;
Siqueira MG, Martins RS. Surgical treatment of adult traumatic brachial plexus injuries: an overview. Arq Neuropsiquiatr. 2011;69(3):528-535;
Franko OI, Khalpey Z, Gates J. Brachial plexus trauma: the morbidity of hemidiaphragmatic paralysis. Emerg Med J. 2008;25(9):614-615;
Robla-Costales J, Socolovsky M, Di Masi G, et al. Técnicas de reconstrucción nerviosa en cirugía del plexo braquial traumatizadoParte 2: Transferencias nerviosas intraplexuales [Nerve reconstruction techniques in traumatic brachial plexus surgery. Part 2: intraplexal nerve transfers]. Neurocirugia (Astur). 2011;22(6):521-534;
Robla-Costales J, Socolovsky M, Di Masi G, et al. Técnicas de reconstrucción nerviosa en cirugía del plexo braquial traumatizadoParte 1: Transferencias nerviosas extraplexuales [Nerve reconstruction techniques in traumatic brachial plexus surgery. Part 1: extraplexal nerve transfers]. Neurocirugia (Astur). 2011;22(6):507-520;
Chuang DC. Brachial plexus reconstruction based on the new definition of level of injury. Injury. 2008;39(3):S23-S29. doi:10.1016/j.injury.2008.05.012;
Matthews WB. Aids to the examination of the peripheral nervous system. J Neurol Sci. 1977;33(1-2):299;
Bhandari PS, Sadhotra LP, Bhargava P, et al. Surgical outcomes following nerve transfers in upper brachial plexus injuries. Indian J Plast Surg. 2009;42(2):150-160;
Gates DH, Walters LS, Cowley J, Wilken JM, Resnik L. Range of Motion Requirements for Upper-Limb Activities of Daily Living. Am J Occup Ther. 2016;70(1):7001350010p1-7001350010p10. doi:10.5014/ajot.2016.015487;
Martin E, Senders JT, DiRisio AC, Smith TR, Broekman MLD. Timing of surgery in traumatic brachial plexus injury: a systematic review. J Neurosurg. Published online May 1, 2018. doi:10.3171/2018.1.JNS172068;
Acharya AM, Cherian BS, Bhat AK. Diagnostic accuracy of MRI for traumatic adult brachial plexus injury: A comparison study with surgical findings. J Orthop. 2019;17:53-58;
Malessy MJ, Pondaag W, van Dijk JG. Electromyography, nerve action potential, and compound motor action potentials in obstetric brachial plexus lesions: validation in the absence of a "gold standard". Neurosurgery. 2009;65(4):A153-A159;
Chang TN, Lu JC, Lee CH, et al. Double Fascicular Transfer Using Partially Injured Donor Nerves: Is It Powerful Enough to Restore Elbow Flexion in Acute Brachial Plexus Injuries? J Reconstr Microsurg. Published online October 19, 2021.doi:10.1055/s-0041-1736320;
Chang TN, Shafarenko M, Dadouch R, et al. Can a Partially Injured Donor Nerve Restore Elbow Flexion in an Acute Brachial Plexus Injury in Rats?. Plast Reconstr Surg. 2019;144(5):1105-1114;
Socolovsky M, Di Masi G, Battaglia D. Use of long autologous nerve grafts in brachial plexus reconstruction: factors that affect the outcome. Acta Neurochir (Wien). 2011;153(11):2231-2240;
Bhandari PS, Deb P. Use of contralateral spinal accessory nerve for ipsilateral suprascapular neurotization in global brachial plexus injury: a new technique. J Neurosurg Spine. 2016;24(1):186-188.
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