Comparison of Nerve Transfer Outcomes for Elbow Flexion in Acute C5, C6 Brachial Plexus Injuries Between Two Decades
Johnny Chuieng - Yi Lu, MD, MSCI1, Ying - Hsuan Lee, MD2, Tommy Nai-Jen Chang, MD3, David Chwei-Chin Chuang, MD4 and Kee Min Yeow, MD2, (1)Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan, (2)Chang Gung Memorial Hospital, Taoyuan City, Taiwan, (3)Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan, (4)Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
Introduction: Newer nerve transfer techniques have attributed to better outcomes in brachial plexus reconstruction in the past decade. Here we examine the outcomes of 256 patients with acute C5-C6 brachial plexus injuries who were treated in the past 20 years in a tertiary medical center.
Materials and Methods: 112 patients operated from 1995 to 2005 were compared with 144 patients from 2006 to 2016. Patient demographics, operative method, types of donor nerve used were recorded. All patients were evaluated preoperatively and postoperatively to assess the recovery time and muscle strength of elbow flexion. Injuries involving C7 to T1, chronic nerve injuries (>1 year), viral infection and obstetric palsy were excluded.
Results: The average time from injury to nerve reconstruction was 4.3 months, and the average time of follow up was 54.3 months. In the first decade, nerve reconstruction methods included proximal nerve grafting, intercostal nerve transfer, and Oberlin transfer (single fascicular transfer). In the second decade, newer methods such as double fascicular transfer, C7 division transfer to anterior division of upper trunk were introduced, in addition to proximal nerve grafting and intercostal nerve transfer. 76.3% of the first decade group versus 90.2% of the second decade group were able to reach M3 (p = 0.017), but no significant difference in time of recovery to reach M3 (18.2 months vs 19.2 months). 56.3% of the first decade group vs 69.6% of the second decade group were able to reach M4 (p = 0.07), but no significant difference in time of recovery (30.7 months vs 24.3 months), although there was a trend in second decade to be shorter. In both groups, intercostal nerve transfer was the least consistent method to reach M4, while the double fascicular nerve transfer had the highest impact when introduced in the second decade. More precise MRI techniques using the FIESTA view (rootlets), DWI view (ganglion), CUBE and STIR views (trunk and divisions) help diagnose the level of injury, the roots involved and evaluate the health of the donor nerves in preparation for intraplexus transfer (Figure 1). Routine neck exploration was performed in all patients (Figure 2).
Conclusions: In addition to modified techniques in nerve transfers, 1) MRI assisted evaluation and surgical exploration of the roots with 2) more judicious choice of donor nerves for primary nerve transfer were factors that ensured reliable and outcomes in the second decade.
Figure 1A
Figure 1B
Figure 2
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