Use of Intercostal Nerve Transfer for Restoration of Shoulder Function After Virally-Induced Spinal Cord Injuries
Ryan A Hoffman, MD, Einstein Healthcare Network, Philadelphia, PA, Matthew DeWolf, MD, Philadelphia Hand to Shoulder Center, Philadelphia, PA, Paula A Pino, MD, Pontifical Catholic University of Chile Santiago, Santiago, Chile and Dan A Zlotolow, MD, Shriners Hospital for Children Philadelphia, Philadelphia, PA
Introduction:
Abduction and external rotation are essential for shoulder stabilization. Clinical entities including brachial plexus injuries, acute flaccid myelitis (AFM), and transverse myelitis (TM) can lead to paralysis of the deltoid and rotator cuff muscles, resulting in loss of these motions. AFM and TM patients have limited options for nerve transfers; however, preservation of intercostal nerves (ICN) is often present. This study describes use of ICNs as donor transfers to the axillary and suprascapular nerves to restore shoulder abduction and external rotation in patients with AFM and TM.
Methods:
This was a retrospective cohort approved by the institutional review board. Patients who underwent ICN transfers to the axillary, suprascapular, or both nerves for restoration of shoulder function were enrolled. All surgical procedures were performed by a senior Orthopedic surgeon. Outcome scores were determined by the Active Movement Scale (AMS) assessment. These scores were determined by formal evaluation from licensed occupational therapists pre and post-operatively. Nerve transfer outcomes for abduction and external rotation of the shoulder were categorized into poor (AMS=0-4), good (AMS=5), and excellent (AMS=6-7). Pseudosubluxation was also recorded at pre-and post-operative visits. Children qualified for nerve transfers after presentation with a neurologic injury resulting in loss of functional abduction or external rotation (AMS<5) at a minimum of 6 months with a plateau in clinical improvement.
Results:
Of the nine enrolled patients, eight suffered from AFM and one from TM. The mean age and time interval from nerve injury to surgery was 60.27 and 8.37 months (range 1.86-12.33), respectively.
The mean preoperative AMS score for shoulder abduction and external rotation were 0.44 (range 0-2) and 1 (range 0-3), respectively. One patient obtained functional shoulder abduction after surgery (AMS >5). Three patients were able to achieve functional external rotation of the shoulder post-operatively (AMS >5).
Average post-operative AMS scores at 1 year were 1.5 and 3.33 for shoulder abduction and external rotation, respectively. Final AMS scores were determined to be 3 for abduction and 5 for external rotation. The average time to maximal AMS was 19 months for abduction and 19.25 months for external rotation.
Pseudosubluxation was identified in six patients pre-operatively, with complete resolution is all post-operatively.
Conclusion:
Our data suggest that ICN transfers have limited efficacy in restoring shoulder function, but remain a viable option for improving abduction and external rotation in patients with AFM and TM.
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