Nerve Transfers For BPAI—Huashan(China)Experience
Jg Xu, MD, PHD; Z Dong, MD; SN Hu, MD, PhD; L Xu, MD, PHD; T Wang, MD, PHD; WD Xu, MD, PhD; J Lao, MD, PHD; L Chen, MD, PhD; Xm Chen, MD; DS Chen, MD; GM Zhang, MD; Jg Yan, MD; Yd Gu, MD
Huashan Hospital, Fudan University, Shanghai, China
This report presents our over fifty years of experience using nerve transfer for treating brachial plexus avultion injury (BPAI). Clinically, we classify the common BPAI into three types: 1) upper trunk, 2) lower trunk, 3) entire brachial plexus avulsion injury. We design corresponding treatment strategies accordingly.
For upper trunk injury, the most common type, our first choice is combined transfer of Accessory N to Suprascapular N, Triceps branch of radial N to Axillary N, together with Oberlin procedure. Other options include transferring Intercostal N to Musculocutaneous N combined with Triceps branch to Axillary N. Sometimes, Phrenic N transfer to the Musculocutaneous N combined with Triceps branch to Axillary N is performed. Another option is selective Ipsilateral C7 transfer to upper trunk as per established methods for finding functional nerve fascicles, based on proven basic studies and clinical practice. When Accessory N is injured, intercostal nerves are transferred to Suprascapular and Triceps branch to Axillary N.
For lower trunk injury, our first choice is restoring finger flexion by combined transfer of pronator teres branch to AIN and brachialis branch to FDS. And then transfer the tendon of brachioradialis M to abductor pollicis brevis to reconstruct thumb opposition. Sensation is restored by transferring superficial branch of the radial N to that of the ulnar N. Second choice is transferring Contralateral C7 to anterior division of lower trunk, combined with tendon transfer. For lower+middle trunk injury, relatively rarer, we transfer pronator teres branch to AIN, plus Brachialis Branch to FDS Branch. The flexor strength can henceforth reach M4. In addition, we transfer Supinator Branch to PIN, restoring MPJ extension.
For total BPAI, there are multiple options. We may transfer Accessory N to Suprascapular N, Phrenic N to Musculocutaneous N, and Intercostal N to Radial N, and/or Suprascapular N, and/or Musculocutaneous N. We may also transfer CC7 to Median N and/or Musculocutaneous N and/or Radial N, even onto lower/upper trunk through pedicle ulnar N or sural N grafting.
We have made improvements in the procedure of CC7 nerve transfer, including changing from subcutaneous to prevertebral routing. For the bridging nerves, we use sural N or ulnar N combined with dorsal branch, sometimes plus medial antebrachial cutaneous N or sural N. We have evolved from targeting a single nerve to multiple nerves. And others such as lidocaine blockage, dual blood supply are also key factors for consideration during the surgery.
Back to 2017 ePoster Listing