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Augmentation of partially regenerated nerves by end-to-side side-to-side grafting neurotization: experience based on eight late obstetric brachial plexus cases.

Amr SM, Moharram AN, Abdel-Meguid KM - J Brachial Plex Peripher Nerve Inj (2006)

Bottom Line: Differential regeneration of muscles supplied by the same nerve was observed secondly (superior supraspinatus to infraspinatus regeneration).Differential regeneration of antagonistic muscles was observed thirdly (superior biceps to triceps and pronator teres to supinator recovery).As it is less expected to improve infraspinatus power, it should be associated with a humeral derotation osteotomy and tendon transfer.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedics and Traumatology, Cairo University, Cairo, Egypt. sherifamrh@yahoo.co.uk

ABSTRACT

Objective: The effect of end-to-side neurotization of partially regenerated recipient nerves on improving motor power in late obstetric brachial plexus lesions, so-called nerve augmentation, was investigated.

Methods: Eight cases aged 3-7 years were operated upon and followed up for 4 years (C5,6 rupture C7,8 T1 avulsion: 5; C5,6,7,8 rupture T1 avulsion: 1; C5,6,8 T1 rupture C7 avulsion: 1; C5,6,7 rupture C8 T1 compression: one 3 year presentation after former neurotization at 3 months). Grade 1-3 muscles were neurotized. Grade 0 muscles were neurotized, if the electromyogram showed scattered motor unit action potentials on voluntary contraction without interference pattern. Donor nerves included: the phrenic, accessory, descending and ascending loops of the ansa cervicalis, 3rd and 4th intercostals and contralateral C7.

Results: Superior proximal to distal regeneration was observed firstly. Differential regeneration of muscles supplied by the same nerve was observed secondly (superior supraspinatus to infraspinatus regeneration). Differential regeneration of antagonistic muscles was observed thirdly (superior biceps to triceps and pronator teres to supinator recovery). Differential regeneration of fibres within the same muscle was observed fourthly (superior anterior and middle to posterior deltoid regeneration). Differential regeneration of muscles having different preoperative motor powers was noted fifthly; improvement to Grade 3 or more occurred more in Grade 2 than in Grade 0 or Grade 1 muscles. Improvements of cocontractions and of shoulder, forearm and wrist deformities were noted sixthly. The shoulder, elbow and hand scores improved in 4 cases.

Limitations: The sample size is small. Controls are necessary to rule out any natural improvement of the lesion. There is intra- and interobserver variability in testing muscle power and cocontractions.

Conclusion: Nerve augmentation improves cocontractions and muscle power in the biceps, pectoral muscles, supraspinatus, anterior and lateral deltoids, triceps and in Grade 2 or more forearm muscles. As it is less expected to improve infraspinatus power, it should be associated with a humeral derotation osteotomy and tendon transfer. Function to non improving Grade 0 or 1 forearm muscles should be restored by muscle transplantation.

Level of evidence: Level IV, prospective case series.

No MeSH data available.


Related in: MedlinePlus

a. Case 1: 1 year after surgery on the right side, no improvement has yet occurred. She was operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. The anterior deltoid was Grade3, the lateral deltoid Grade2, the posterior deltoid Grade0. Note the supination deformity of the forearm, the extension deformity at the wrist and biceps cocontraction on attempted active shoulder abduction. At this stage, with that degree of weak shoulder abduction, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will be of no avail. b. Case 1: 2 years after surgery. The anterior deltoid became Grade5, the lateral deltoid Grade4 and the posterior deltoid Grade2. The wrist extensors improved from Grade1 up to Grade3. Some degree of pronation has been regained at the forearm. At this stage, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will also be of no avail, because of extensive biceps cocontraction on attempted shoulder abduction. c. Case7: 4 years after surgery on the right side. She was also operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. In addition to improvement of the deltoid and wrist extensors, some shoulder external rotation has been regained as the infraspinatus became Grade3. Biceps cocontraction on attempted shoulder abduction improved. She may therefore benefit from secondary corrective procedures at the shoulder. In addition, a free functional gracilis transplantation has to be carried out to power the weak finger flexors.
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Figure 1: a. Case 1: 1 year after surgery on the right side, no improvement has yet occurred. She was operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. The anterior deltoid was Grade3, the lateral deltoid Grade2, the posterior deltoid Grade0. Note the supination deformity of the forearm, the extension deformity at the wrist and biceps cocontraction on attempted active shoulder abduction. At this stage, with that degree of weak shoulder abduction, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will be of no avail. b. Case 1: 2 years after surgery. The anterior deltoid became Grade5, the lateral deltoid Grade4 and the posterior deltoid Grade2. The wrist extensors improved from Grade1 up to Grade3. Some degree of pronation has been regained at the forearm. At this stage, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will also be of no avail, because of extensive biceps cocontraction on attempted shoulder abduction. c. Case7: 4 years after surgery on the right side. She was also operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. In addition to improvement of the deltoid and wrist extensors, some shoulder external rotation has been regained as the infraspinatus became Grade3. Biceps cocontraction on attempted shoulder abduction improved. She may therefore benefit from secondary corrective procedures at the shoulder. In addition, a free functional gracilis transplantation has to be carried out to power the weak finger flexors.

Mentions: Exemplary for this was the deltoid muscle, its anterior and middle fibres regenerating better than its posterior fibres both before and after surgery. Before surgery, the median motor power of the anterior fibres was Grade3 (range:2–5), that of the middle fibres Grade2 (range:2–4) and that of the posterior fibres Grade0 (range:0–2). After surgery, the median motor power of the anterior fibres improved to Grade5 (range:3–5), that of the middle fibres to Grade4 (range:3–4) and that of the posterior fibres to Grade2 (range:0–4) (see Figs 1a and 1b).


Augmentation of partially regenerated nerves by end-to-side side-to-side grafting neurotization: experience based on eight late obstetric brachial plexus cases.

Amr SM, Moharram AN, Abdel-Meguid KM - J Brachial Plex Peripher Nerve Inj (2006)

a. Case 1: 1 year after surgery on the right side, no improvement has yet occurred. She was operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. The anterior deltoid was Grade3, the lateral deltoid Grade2, the posterior deltoid Grade0. Note the supination deformity of the forearm, the extension deformity at the wrist and biceps cocontraction on attempted active shoulder abduction. At this stage, with that degree of weak shoulder abduction, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will be of no avail. b. Case 1: 2 years after surgery. The anterior deltoid became Grade5, the lateral deltoid Grade4 and the posterior deltoid Grade2. The wrist extensors improved from Grade1 up to Grade3. Some degree of pronation has been regained at the forearm. At this stage, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will also be of no avail, because of extensive biceps cocontraction on attempted shoulder abduction. c. Case7: 4 years after surgery on the right side. She was also operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. In addition to improvement of the deltoid and wrist extensors, some shoulder external rotation has been regained as the infraspinatus became Grade3. Biceps cocontraction on attempted shoulder abduction improved. She may therefore benefit from secondary corrective procedures at the shoulder. In addition, a free functional gracilis transplantation has to be carried out to power the weak finger flexors.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC1764873&req=5

Figure 1: a. Case 1: 1 year after surgery on the right side, no improvement has yet occurred. She was operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. The anterior deltoid was Grade3, the lateral deltoid Grade2, the posterior deltoid Grade0. Note the supination deformity of the forearm, the extension deformity at the wrist and biceps cocontraction on attempted active shoulder abduction. At this stage, with that degree of weak shoulder abduction, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will be of no avail. b. Case 1: 2 years after surgery. The anterior deltoid became Grade5, the lateral deltoid Grade4 and the posterior deltoid Grade2. The wrist extensors improved from Grade1 up to Grade3. Some degree of pronation has been regained at the forearm. At this stage, a humeral external rotation osteotomy or latissimus dorsi to rotatotar cuff transfer will also be of no avail, because of extensive biceps cocontraction on attempted shoulder abduction. c. Case7: 4 years after surgery on the right side. She was also operated upon at the age of 4 for a C5,6 rupture C7,8T1 avulsion, when phrenic to suprascapular and contralateral C7 to lateral, medial and posterior cord neurotization was carried out. In addition to improvement of the deltoid and wrist extensors, some shoulder external rotation has been regained as the infraspinatus became Grade3. Biceps cocontraction on attempted shoulder abduction improved. She may therefore benefit from secondary corrective procedures at the shoulder. In addition, a free functional gracilis transplantation has to be carried out to power the weak finger flexors.
Mentions: Exemplary for this was the deltoid muscle, its anterior and middle fibres regenerating better than its posterior fibres both before and after surgery. Before surgery, the median motor power of the anterior fibres was Grade3 (range:2–5), that of the middle fibres Grade2 (range:2–4) and that of the posterior fibres Grade0 (range:0–2). After surgery, the median motor power of the anterior fibres improved to Grade5 (range:3–5), that of the middle fibres to Grade4 (range:3–4) and that of the posterior fibres to Grade2 (range:0–4) (see Figs 1a and 1b).

Bottom Line: Differential regeneration of muscles supplied by the same nerve was observed secondly (superior supraspinatus to infraspinatus regeneration).Differential regeneration of antagonistic muscles was observed thirdly (superior biceps to triceps and pronator teres to supinator recovery).As it is less expected to improve infraspinatus power, it should be associated with a humeral derotation osteotomy and tendon transfer.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Orthopaedics and Traumatology, Cairo University, Cairo, Egypt. sherifamrh@yahoo.co.uk

ABSTRACT

Objective: The effect of end-to-side neurotization of partially regenerated recipient nerves on improving motor power in late obstetric brachial plexus lesions, so-called nerve augmentation, was investigated.

Methods: Eight cases aged 3-7 years were operated upon and followed up for 4 years (C5,6 rupture C7,8 T1 avulsion: 5; C5,6,7,8 rupture T1 avulsion: 1; C5,6,8 T1 rupture C7 avulsion: 1; C5,6,7 rupture C8 T1 compression: one 3 year presentation after former neurotization at 3 months). Grade 1-3 muscles were neurotized. Grade 0 muscles were neurotized, if the electromyogram showed scattered motor unit action potentials on voluntary contraction without interference pattern. Donor nerves included: the phrenic, accessory, descending and ascending loops of the ansa cervicalis, 3rd and 4th intercostals and contralateral C7.

Results: Superior proximal to distal regeneration was observed firstly. Differential regeneration of muscles supplied by the same nerve was observed secondly (superior supraspinatus to infraspinatus regeneration). Differential regeneration of antagonistic muscles was observed thirdly (superior biceps to triceps and pronator teres to supinator recovery). Differential regeneration of fibres within the same muscle was observed fourthly (superior anterior and middle to posterior deltoid regeneration). Differential regeneration of muscles having different preoperative motor powers was noted fifthly; improvement to Grade 3 or more occurred more in Grade 2 than in Grade 0 or Grade 1 muscles. Improvements of cocontractions and of shoulder, forearm and wrist deformities were noted sixthly. The shoulder, elbow and hand scores improved in 4 cases.

Limitations: The sample size is small. Controls are necessary to rule out any natural improvement of the lesion. There is intra- and interobserver variability in testing muscle power and cocontractions.

Conclusion: Nerve augmentation improves cocontractions and muscle power in the biceps, pectoral muscles, supraspinatus, anterior and lateral deltoids, triceps and in Grade 2 or more forearm muscles. As it is less expected to improve infraspinatus power, it should be associated with a humeral derotation osteotomy and tendon transfer. Function to non improving Grade 0 or 1 forearm muscles should be restored by muscle transplantation.

Level of evidence: Level IV, prospective case series.

No MeSH data available.


Related in: MedlinePlus