American Society for Peripheral Nerve

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Fascicular Shifting in the Reconstruction of Global Obstetric Brachial Plexopathies – From Bench to Bedside
Matthias E Sporer, MD; Johannes Mayer, MD; Oskar C. Aszmann, MD, PhD
CD Laboratory for Restoration of Extremity Function, Vienna, Austria

Background: A number of models have investigated different biological and synthetic matrices as alternatives to conventional nerve grafts. However, the autologous nerve graft remains the gold-standard, even though here a pure sensory nerve is used to reconstruct mixed or pure motor nerves. Furthermore, limited donor sites often necessitate a significant mismatch of needed nerve tissue. Especially in the reconstruction of large proximal nerve defects, such as obstetric brachial plexopathies, we are facing these challenges. Here we present a new concept that overcomes these problems: the fascicular shift procedure. A fascicle group of the nerve segment distal to the injury site is harvested in appropriate length to bridge the injury site.

Animal model: In a rat model the fascicular shift was compared to nerve reconstruction with sensory, motor and mixed nerve grafts. The fascicular shift provided sufficient guidance to overcome nerve defects, had higher (P<0.1) motor neuron counts (1958.75±657.21) compared to sensory graft (1263.50±538.90) and was equal to motor (1490.43±794.80) and mixed grafts (1720.00±866.421). This tendency of improved motor regeneration was confirmed in all analyses. None of the analyses revealed an impairment on nerve regeneration despite of the partial defect elongation induced by the fascicular shift distal to the repair site.

Clinical work: At our department a total amount of eight large, proximal nerve defects have been reconstructed by applying fascicular shifting. The presentation of first clinical results will be limited to a long term follow-up of four obstetric brachial plexopathies. Satisfying sensory and functional recovery was found in all patients, which was evaluated amongst others by the Modified Mallet Score (in avg. 3.9 out of 5), the Gilbert Shoulder (in avg. 4 out of 5) and Elbow Scale (in avg. 2.5 out of 3) and the Raimondi Score (in avg 2.4 out of 5).

Conclusion: Experimental investigations and clinical results both show that harvesting a transplant from the nerve segment distal of the injury site provides a mixed graft without causing additional donor-site morbidity. These grafts perform statistically better than a standard sensory graft in regards to motor recovery. The fascicular shift presents a novel method to reconstruct large proximal nerve defects, and thus make it immensely attractive in brachial plexus reconstruction.


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