Shoulder Function Reconstruction in Upper Brachial Plexus (C5-C6) Injuries by Nerve Transfers. A Technique to Improve Shoulder External Rotation
Jorge Clifton, MD1; Eduardo Pablo Zancolli, MD2
1Clinica Mielina Brachial Plexus, Guadalajara, Mexico; 2Fundacion Favaloro, Buenos Aires, Argentina
Background: In Upper Plexus Injuries C5-C6, restoration of elbow flexion, shoulder abduction and external is required. When proximal root stumps are not available for nerve grafting such as in avulsion injuries, or when the time from the injury won't allow a brachial plexus primary reconstruction to reinnervate motor end plates; functional loss can be re establish through nerve transfers if the timing from the injury is suitable for the procedure. Double nerve transfers have shown better outcomes restoring each shoulder function. Purpose: The authors describe a surgical technique through an axillary approach for the reconstruction of shoulder function in upper brachial plexus injuries, to obtain better outcomes of shoulder external rotation by selectively neurotizing the teres minor and the anterior axillary nerve branches. Methods: Surgical procedure was done in 10 patients with C5-C6 injuries were nerve transfers are indicated, in the context of spinal accessory nerve (SAN) to supraescapular nerve (SSN) transfer and double Oberlin procedure to restore shoulder and elbow function. An axillary approach to access the radial and axillary nerves was used. By following the long head of the triceps nerve branch distally into the arm from the axilla, a terminal nerve division was obtained before the nerve enters into the triceps muscle. This branch and its terminal divisions were used to selective neurotize the anterior branch of the axillary nerve and the nerve to the teres minor muscle. Results: All patients obtain a muscle grading strength of 4 or more of shoulder external rotation in adduction and 90 degrees shoulder abduction. Conclusion: This technique has the advantage of neurotizing the anterior motor component of the axillary nerve and teres minor without any axon loss in the sensory or articular distribution of the axillary nerve. SAN to SSN and Radial nerve branch to teres minor accomplished the concept of double nerve transfers to restore shoulder external rotation. By this means shoulder external rotation outcomes are improved either in shoulder adduction and abduction. The use of an axillary approach permits keeping the patient in a supine position during the whole procedure.
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