Shifting the Paradigm: The Case for Standardization of Intercostal Nerve Transfers in Severe Brachial Plexus Injuries
Myron L Rolle, MD1, Gabriel Friedman, MD1 and Justin Brown, MD2, (1)Harvard, Boston, MA, (2)Massachusetts General Hospital, Boston, MA
Shifting the Paradigm: The Case for Standardization of Intercostal Nerve Transfers in Severe Brachial Plexus Injuries
Myron L Rolle MD, Gabriel Friedman MD, Justin M Brown MD
Introduction
Traumatic brachial plexus injuries can lead to loss of upper extremity motor and sensory function with few options for reanimation. An often under-utilized approach for brachial plexus reconstruction is via the intercostal nerves (ICNs).
Objective
Demonstrating a technique of multiple intercostal nerves for transfer allowing the targeting of multiple muscle groups and avoidance of grafting.
Methods
With patients supine, a curvilinear incision is made following the 7th rib from midline back to the midaxillary line. This incision is carried along the midaxillary line back to the axilla anteriorly, into the proximal medial arm. The skin flap is held in position to facilitate the lifting of the flap. After mobilizing the skin flap, we lift the serratus anterior muscle from its lowest 4-5 insertions, marking each for later reapproximation. The serratus is retracted giving access to the chest wall posterior to the mid-axillary line. Each rib is skeletonized (typically 6 ribs, 2-7) and the periosteum is lifted. This periosteum is opened and each intercostal nerve is identified, neurolysed and followed as medially as possible and then laterally, to at least the mid-axillary line. The lower ICNs typically have a second branch to the superficial abdominal muscles which provides notable additional transferrable axons. Each of the lower ICNs followed to at least the mid-axillary line can reach the axilla for repair. A serratus perforation is made and the nerves are tunneled through this. If the serratus is denervated, we advocate for reinnervation of this by passing its associated long thoracic nerve retrogradely through the same perforation to be coapted to the abdominal branches of the lower ICNs.
Results
Using 6 ICNs for reconstruction is safe and efficacious, bringing larger caliber ICNs with larger axon complements to the axilla for repair to plexus elements. Candidate targets include: musculocutaneous nerve, medial cord, lateral cord, median nerve, anterior division of axillary nerve, long head of triceps branch of radial nerve.
Conclusion
In complete brachial plexus injuries, donor nerve options are limited. To have 6 reliably accessible ICNs to contribute to the reconstruction is critical in the reconstruction strategy. Surgeons should strongly consider ICNs for reanimation in brachial plexus injuries.
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