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Prespinal Contralateral C7 Transfer for Total Palsy in Birth-Related Brachial Plexus Injury
Ann Schwentker, MD; Kevin Yakuboff, MD
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
In birth-related brachial plexus palsy with involvement of the entire upper extremity including the hand, there is a paucity of ipsilateral nerve donors for adequate reconstruction. Frequently there are two or fewer nerve roots of variable quality available for nerve grafting, along with the distal spinal accessory and intercostal nerves. The contralateral c7 root has been used with a vascularized ipsilateral ulnar nerve graft, but has been criticized because of the risk of bilateral dissection, especially to the phrenic nerve. In infants, with the potential for eventual good distal function, sacrifice of the ulnar nerve may limit functional recovery of the hand.
We present early results of a new protocol at our institution whereby total palsy is treated with early exploration of the brachial plexus and neurotization of the lower trunk with a contralateral c7 transfer passed via a prespinal route. This results in a very short gap that may be bridged with a cabled sural nerve graft and does not require sacrifice of the ulnar nerve. We have seen temporary weakness of the donor triceps muscle in 2/3 cases, and no permanent deficits of the contralateral arm. Exposure via a transverse incision in a neck crease results in minimal scarring. There have been no cases of phrenic paresis on the donor side. There has been no prolongation of hospital stay, no need for ICU admission, relatively short operative time, no need for postoperative intubation, no dysphagia, and no neck or airway edema following the procedure.
Three cases have been performed at our institution. Operative time averaged *** hours (***-***). The sural nerve grafts ranged from 2.5-4.5 cm in length to reach the lower trunk. Dissection behind the esophagus through the prespinal space is avascular and accomplished with gentle blunt dissection. Blood loss has averaged less than 25 cc. Specifics of preoperative and intraoperative decision-making and operative technique will be discussed.
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