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IFSSH Scientific Committee
on Brachial Plexus Injury

Yuan-Kun Tu (Taiwan)


May 2016

equipment. 23,24,25,26 However, the

external rotation in C5 and C6 roots

be performed prior to brachial plexus

results of direct nerve repair or

injury. The physical examination

exploration. Typically, the first EMG

free nerve grafting for BPI did not

of individual muscle function

and NCV are performed 6 weeks

obtain satisfactory clinical results,

reveals that paralysis of the biceps,

following trauma, and the second

which altered the trends of BPI

brachialis, deltoid, and the rotator cuff

EMG / NCV studies are performed 3

reconstruction toward the technique

are seen commonly,

to 4 months after injury if indicated. If

of nerve transfers.

additional loss of wrist dorsiflexion

no progress is identified on the EMG /

French physiologist Marie Jean

or finger extension implies that the

NCV or during physical examination,

1-5, 9-21, 24, 27

In 1824,

12, 16, 17

while the


Pierre Flourens was the first to

C7 root is also damaged with possible

then a CT myelogram or MRM is

theorize that an injured nerve could

concomitant incomplete lower trunk

obtained and plexus exploration is


be bypassed by suturing the superior

(C8, T1) injury.


end of one nerve with the inferior end

findings can be reasonably explained

of the other nerve.

by understanding the anatomy of

Philosophy and concepts of upper

brachial plexus (Figure 1).

arm type BPI reconstruction


But the first


These physical

Current Trends in the Management


especially in avulsion root injuries

brachial plexus reconstruction by

of Adult Brachial Plexus Palsy

Injuries to major nerves of the

or for denervated targets that are

using the nerve transfer technique

Part I: Upper arm type

upper extremities, especially the

farthest from the injury sites.

was reported on a 20 year old female

In addition to physical examination,

regeneration following injury;

brachial plexus, have devastating

Hence, regenerative distance and time

injured by a Nazi bomb blast. The

the diagnosis of upper arm type

however the clinical results regarding


consequences owing to the resultant

to reinnervation represent some of

surgery was performed prior to the

BPI is confirmed by serial needle

recovery remain elusive.1, 2, 4 As we

The brachial plexus consists of

motor, sensory, and autonomic

the key determinants of functional

advent of microsurgical instruments

electromyography (EMG) and nerve

understand that once the nerve begins

cervical nerve roots C5, C6, C7, C8, and

function loss associated with such

outcomes after injuries to brachial

/ equipment, by a Russian surgeon,

conduction velocity (NCV) studies, CT

to regenerate, it moves at around 1-1.5

thoracic nerve root T1. Upper arm type

injuries. Unfortunately, such

plexus nerve trunks.

Alexander Lurje, in 1948. Our

myelograms, and magnetic resonance

mm daily. 2, 12, 31

brachial plexus injury (BPI) means C5

injuries are occurring with increasing

transfers (neurotization) represent a

improved understanding of nerve

myelography (MRM).5, 9, 12

and C6 root injury with or without C7

frequency, owing to high-velocity

relatively novel approach to restore

pathophysiology, anatomy, repair, and

These diagnostic tools are required to

injury. Nerve injury caused by sharp

civilian injuries (motor vehicle and

useful upper limb function after

reconstruction has led to advances in

cut or stab injury might be treated

motorbike accidents) and, more

severe proximal nerve injuries in BPI.

the treatment options for upper arm

with direct repair with or without

recently, war related injuries seen

Nerve transfer technique reduces the

type BPI in the past 30 years.

a nerve graft. However, for most of

in war veterans. Patients suffering

distance to reinnervate target organs

the BPIs which were caused by high

from upper arm type BPI present with

by delivering expendable motor

Physical examinations and

velocity trauma, nerve root avulsion

loss of motor function in shoulder

and/or sensory axons close to the

diagnostic tools for upper arm type

or rupture require nerve transfer

elevation / abduction / external

denervated end organs.


(neurotization) to bypass the damaged

rotation, and elbow flexion. The other

zone thereby allowing patients to

major clinical problems are pain and

History of BPI and reconstruction

traction injury, in which the head

regain critical shoulder and elbow

loss of adequate sensory function.

Brachial plexus injuries have been

is forcefully distracted from the

functions faster. In this review article,

Microsurgical repair of injured

reported directly or indirectly for the

ipsilateral shoulder. This manner

we present various reconstructive

nerves has achieved significant

last 2800 years. The first mention

of traction force typically results

nerve / tendon transfer techniques for

advancement, but the functional

of a BPI in the literature occurs in

the management of adult upper arm

recovery is still suboptimal.

Homer’s “The Iliad” around 800BC.

post-ganglionic rupture of the upper

type BPI. With the modern advances

microsurgical repair of injured

The attempts to reconstruct the

trunk (C5-C6) and middle trunk (C7),

of microsurgery, the shoulder and

nerves, especially in sharp cut and

BPI by direct suturing the ruptured

while sparing the lower trunk (C8

elbow functions can be successfully

stab injury, represent the best repair

nerve stumps, or free interposition

and T1). 9 The typical findings in

recovered in around 80% to 90% of

strategy when feasible. However,

sural nerve grafting had gained its

physical examination for upper arm

upper arm type BPI patients.

even with such repairs, return of

popularity after the development

type BPI are the loss of elbow flexion

Figure 1: Anatomical diagram of the brachial plexus. The spinal accessory

useful function cannot be guaranteed,

of microsurgical techniques and

and shoulder elevation / abduction /

nerve originating from C2-C4 is also shown.






4, 5, 9-13




1-4, 9-12, 14-21

Many studies document nerve

The mechanism of most BPIs is a

in pre-ganglionic root avulsion or




May 2016

The motor endplates with which the

spinal accessory nerve, phrenic nerve,

joint passive range of motion during

transfers are not as satisfactory as

for both elbow and hand functions.

anatomical coaptation between

nerve communicates will eventually

intercostal nerve, or contralateral

the interval between a nerve transfer

intra-plexus nerve transfers, especially


proximal and distal nerve fibers. In

cease to function in 12-18 months.

C7 root) are the methods of choice

procedure and target muscle power

for elbow flexion.

If a proximal plexus injury occurs,

for BPI construction.


extent of initial nerve trauma plays

Nerve repair, nerve grafting, and

between C5 and C6 roots proximally

then the regenerated nerve may not

Re-implanting avulsed spinal roots

an important role in determining the

nerve transfer options for elbow

and in the upper trunk level distally,

reach the motor endplate in time to be

directly into the spinal cord for the

The second factor is the timing

surgical outcomes in BPI.

flexion in upper arm type BPI

the sural nerve graft coaptation suture

effective. Therefore, using the nerve

reconstruction of pre-ganglionic

of reconstruction. Many studies

Nerve repair is indicated for the

with C5 should be connected to the

transfer technique of harvesting nerve

avulsion BPI has been reported from

have shown that nerve transfers

The fourth factor is the priority of

treatment of open wounds with clean

distal stump with the part of the

fascicles from uninjured nerve and

the United Kingdom with acceptable

performed within 6 months post-

functional reconstruction. The two

transection of a part of the brachial

cross-sectional surface that forms

transferring to the injured nerve (close-

clinical outcomes.

injury yield results superior to

most important functions which

plexus, if the proximal and distal

the posterior division; whereas the

target neurotization) may facilitate the

nerve root re-implantation technique

transfers performed after 6 months

need to be restored in upper arm type

stumps can be clearly identified.

sural nerve graft coaptation with C6

salvage of critical motor endplates and

has not been popularly used in the


BPI are elbow flexion and shoulder


their corresponding muscles.

field of brachial plexus reconstruction.

interval between injury and nerve

abduction / elevation / external

proximal and distal stumps of the

anterior division of the cross-sectional

reconstruction surgery is more


disrupted musculocutaneous nerve,

surface distally.3,9,24,25,32,33,48




However, this

This nerve re-routing essentially


When the


Therefore, the


upper arm type BPI, if the defect is

Direct coaptation of the

proximally should be connected with

converts a proximal nerve injury into a

Factors influencing the outcomes of

than 9 to 12 months after trauma,

Elbow flexion is critical to human

the lateral cord, or the C5-C6 upper

distal nerve injury closer to the motor

nerve transfers

then the surgical options are either

interaction with the environment,

trunk by microsurgical techniques

However, in cases with longer nerve

endplate and denervated muscle.

The outcomes of nerve transfers for

tendon transfer or free functioning

and its restoration is the principal

may obtain the most predictable and

defects, the anatomical cross-sectional

By this neurotization method, the

BPI patients depend on four factors

muscle transfer, instead of nerve

goal of BPI reconstruction. This is

reliable clinical outcomes.

coaptation suture with sural nerve

proximal nerve stump can reach the

which may influence the clinical


particularly true in C5-C6 injuries

target muscle before motor endplate

results. The first factor is patient


selection. Studies have shown that



graft seems to be impractical. Because

where the musculocutaneous nerve

Nerve grafting is indicated in cases

there is not enough autologous donor

The third factor is the extent of

(MCN) has been compromised. The

with loss of continuity, either caused

nerve available to restore continuity to

younger patients recover from nerve

initial nerve trauma. We are aware

MCN innervates the biceps and

by sharp or traction injury at the level

all parts of the plexus, and nerve fiber

Post-ganglionic root sharp-cut and

transfer faster and ultimately have

that many nerve transfer methods

brachialis which are the elbow flexors.

of the post-ganglionic level, trunk level,

exchange within long segments loss

rupture injuries are amenable to

better outcomes than older patients.

such as Oberlin I nerve transfer

Restoration of elbow flexion can

or cord level. Since it remains doubtful

of the brachial plexus is high, there is

primary nerve repair and nerve

Typically patients under 40 years of

(fascicle of ulnar nerve transfer

significantly improve the activities of

whether useful regeneration can occur

a high possibility of nerve fiber loss

grafting, whereas pre-ganglionic

age have the best functional outcomes

to musculocutaneous nerve), and

daily living for the BPI patient.

in a reasonable time, the neuroma

after nerve grafting surgeries due to

avulsion lesion injuries require

following nerve transfer.

Somsak’s method (branch of radial

Restoration of shoulder stabilization

should be resected. After the proximal

the deviation of regenerating axons.

nerve transfers.

addition to age, some other factors

nerve transfer to axillary nerve)

and elevation / abduction / external

and distal stumps have been properly

Therefore, it is more practical and has

intra-plexus nerve transfers (such

such as tobacco use, body mass index

have quite satisfactory outcomes

rotation are the second most

prepared after neuroma resection,

been proven to be more successful to

as ulnar nerve or median nerve

(BMI), patient’s compliance, and social-

in C5 and C6 roots injury. However,

important priorities in primary

a direct nerve coaptation suture is

connect proximal stumps directly with

transfer to musculocutaneous nerve,

economical status also influence the

when injury involves not just the

reconstruction of BPI.

usually impossible, due to fibrosis

distal nerves, instead of a connection

and radial nerve transfer to axillary

surgical outcomes of BPI patients.

C5 and C6 roots, but also the C7 root

In addition to suprascapular nerve

and shrinkage of nerve stumps after

with ill-defined distal stumps at trunk

nerve) remain the best options for

10, 18,21,40,41

or partial damage of lower trunk,

(innervation of the supra- and infra-

trauma. If the nerve defect is short,

or division levels. For instance, if there

pre-ganglionic root avulsion injuries,

tend to result in less satisfactory

the intra-plexus nerve transfers are

spinatus muscles of rotator cuff), the

then the continuity can be restored by

is a long nerve defect between C5

some injuries which avulse or rupture

outcomes than in patients who do not

not optimal surgical procedures

axillary nerve (innervation of the

an interposition nerve graft. The most

and C6 and the posterior and lateral

more than 80% of the plexus roots are

smoke, or patients who have a normal

for BPI reconstruction.

deltoid muscle) is also compromised

commonly used free nerve graft is

cords in upper arm type BPI, the ideal

not good candidates for nerve transfer

BMI. It is critical that the patient

Surgeons may need to apply the

in C5-C6 injuries.

sural nerves harvested from the legs.

method is to use sural nerve graft

due to the partial loss of the motor

adheres to an occupational therapy

techniques of extra-plexus nerve

to both the suprascapular nerve and

The length of sural nerve is up to 30

connecting the proximal C6 stump

nerves in the lower trunk.

and physical therapy program both

transfers (such as phrenic nerve,

axillary nerve may restore the function

cm long.

directly to the musculocutaneous

these situations (such as complete

before and after surgery. An adequate

spinal accessory nerve, intercostal

of rotator cuff muscles and deltoid

C5,6,7 injury with incomplete C8,T1

scheduled rehabilitation program may

nerve, or contralateral C7 root) for

muscle which may abduct / elevate

Knowledge of the cross-sectional

Then the regenerating nerve fibers

injury), extra-plexus nerve transfers

prevent joint stiffness before nerve

BPI reconstruction.

/ externally rotate, and stabilize the

intraneural topography should be

go directly to the musculocutaneous

(by using neurotization from the

surgery, and may also allow early

The outcomes of extra-plexus nerve

shoulder, providing a solid platform

adequately applied to achieve proper

nerve and provide motor innervation





12, 18, 39



2-5, 9,

The use of tobacco and obesity






Nerve transfers

nerve of the lateral cord distally.



to the biceps and brachialis muscles.


May 2016

should choose the fascicles that

6 (100%) recovering M4 strength. No

markedly increased the success rate of

innervate extrinsic muscles (such as

patient from either study showed any

elbow flexion without sacrificing the

good results for elbow flexion in 70-

flexor carpi ulnaris) for transfer. This

sign of motor or sensory loss.

donor nerve (MN and UN) function in

addition of the MN coaptation has

4, 9,12,15,25,32,33,48

Nerve grafting provides

2, 50, 51


75% of cases with upper arm type BPI.

selective nerve fascicle dissection

3, 15, 23,25,33,48

can prevent a mistake in harvesting

There are several nerve / tendon

the fascicles of UN that supply the

3. Intercostal nerves (ICNs) transfer to

transfer options for the reconstruction

intrinsic muscles and cause donor


of elbow flexion in upper arm type

site deficiency (such as claw hand

The ICN contains approximately


3,000 to 4,000 myelinated fibers, with

Figure 4B: Three ICNs were

each ICN carrying a different number

transferred to the MCN by using 10-0
Nylon coaptation suture.

BPI. The donor nerves applied for BPI

Figure 2B: Two motor fascicles from

neurotization include: ulnar nerve

UN were identified.



(UN), median nerve (MN), intercostal

2. Mackinnon’s method (Oberlin II

of motor and sensory fibers.

nerve (ICN), spinal accessory nerve


3 and 4 ICNs contain a significant

(SAN), phrenic nerve (PN), and medial

Although the Oberlin I method is a

number of motor fibers. ICN transfer

achieving good results. (Figure 4A, 4B)

pectorial nerve (MPN). The recipient

common and practical technique

Figure 3A: Mackinnon’s method

was introduced by Yeoman and

The techniques of ICNs direct

nerve is the musculocutaneous nerve

for reconstructing elbow flexion in

(Oberlin II). The motor branch to

Seddon, but sparked by Japanese

(MCN). The following six techniques

upper arm type BPI, some patients

brachialis muscle was identified.

doctors Tsuyama, Hara, and Nagano.

are the most ommonly used methods.

in the French and Thai studies


unfortunately required further muscle

BPI neurotization, especially for

nerve coaptation suture to ensure

origin transfers (Steindler flexorplasty)

reinnervation of the MCN.

proper nerve regeneration after

1. Oberlin I method:

1, 48




coaptation suture with the MCN

It has been widely used for
9, 45, 48


should be emphasized in two aspects.
The first aspect is the tension-free

The current most commonly used

Figure 2C: The motor fascicles from

to improve elbow flexion. Surgeons

surgical approach for harvesting ICNs

trauma. The second aspect is the

nerve transfer technique for elbow

UN were transferred to the motor

found that when the brachialis muscle

is extended from the usual supra-

concomitant reconstruction of motor

flexion in upper arm type BPI is the

branches from MCN to biceps by 9-0

was also re-innervated in addition

and infra-clavicular incisions at the

and sensory function of the MCN by

Oberlin I transfer which was first

Nylon coaptation suture.

to biceps, the patient achieved

anterior border of the axilla onto the

accurate location of the motor and

described by Christophe Oberlin of

better elbow flexion than biceps re-

infra-areolar (male) or inframammary

sensory components of MCN and

Paris in 1994. He described the transfer

innervation alone.

fold (female) to gain access to the

ICNs. The MCN is the terminal branch


In search of

of one or two nerve fascicles from

This transfer restores elbow flexion

a procedure which could eliminate the

Figure 3B: The motor branch from

ICNs. Direct suture of 2 or 3 ICNs to

of lateral cord. The motor component

the UN directly coapted to the biceps

following loss of the MCN, a branch of

need for additional muscle transfer,

MCN to biceps was also identified.

MCN without nerve graft is the key to

of the MCN is located in the central

motor branch of the MCN (Figure 2A-

lateral cord. In 2004, he reported that

Susan MacKinnon in St. Louis along

and upper zones of cross-section cut,


20 of 32 patients who underwent this

with Christophe Oberlin in Paris

while the sensory component of the

procedure recovered active motion

described the Oberlin II (double)

MCN is located in the peripheral and

against gravity and resistance (M4).

nerve transfers in 2003.

lower zones of the MCN. Therefore,

This procedure was validated by

reconstruction, one fascicle from UN

we recommend transfer of 2 or 3 ICNs

Leechavengvongs in Thailand who

was transferred to MCN, while one

to the MCN by using motor nerves of

reported his experience with 26 of 32

fascicle from MN was transferred to

ICNs direct coaptation suture with

patients (81.3%) who had regained M4

the motor branch to the brachialis

central and upper portions of the MCN

elbow flexion following the Oberlin

muscle. (Figure 3A-C)

cut-surface. And then, the superficial




In this

I transfer. In both studies none of

Figure 3C: The motor fascicle from

Figure 4A: Three intercostal nerves

lateral sensory branches of ICNs

the patients displayed any sequelae

The additional re-innervation of the

MN was transferred to the motor

(ICNs) were identified from the 3rd,

should be sutured onto the peripheral

Figure 2A: Oberlin I neurotization.

from sacrificing an UN fascicle as a

brachialis, a strong elbow flexor, has

branch to brachialis muscle, and

4th, and 5th intercostal spaces with

and lower portions of the MCN cut-

The motor branches to biceps (in this


improved outcomes following loss of

the motor fascicle from UN was

thoracic spinal roots (T3, T4, T5)

surface.10 The M3 elbow flexion is

patients, two branches were found)

adequate donor nerve fascicles of UN

MCN. In 2005, Oberlin reported 15 of 15

simultaneously transferred to the

harvested for transfer.

usually achieved 12 to 18 months after

were identified.

is very important. By using a nerve

patients (100%) recovering M4 elbow

motor branch from MCN to biceps by

surgery. The continuous improvement

stimulator intra-operatively, surgeons

flexion, and Mackinnon reported 6 of

9-0 Nylon coaptation suture.

of M3 to M4 elbow flexion depends on



The technique to choose




May 2016

the intensity of rehabilitation and the

that for the SAN-nerve graft-MCN

patients achieved ≧M3 elbow flexion,

postoperative rehabilitation, the elbow

nerve graft.2 (Figure 5A, 5B).

transfer was essentially abandoned for

compliance of patients. An adequate

technique, the successful rate (≧M3

while 60% of patients gained MRC

flexion after gracilis FFMT may be

Songcharoen and Spinner reported

other transfer options in 2003 when

physical therapy program may allow

elbow flexion) was 83%, while the

grade 4 motor recovery of elbow

recovered around 75% to 80% ≧M3

a good outcome in 74% of their 577

Leechavengvongs from Thailand

patients to achieve M4 elbow flexion

ICNs neurotization on MCN had only

flexion. With the additional C5 or C6

elbow flexion.

SAN-SSN transfers. Terzis and Kostas

described the posterior approach.2,12,47

in 3 years after surgery. During the

64% successful rate. 52 There are two

nerve direct repair, the surgical results

also reported their good and excellent

The Lerdsin group (Leechavengvongs

first 2 years after the operation,

advantages of using the SAN and PN

of elbow flexion might even reach

Nerve / tendon transfer options for

clinical shoulder recovery outcomes

et al. in Thailand) performed a single

biceps function synchronizes with

as motor neurotizers for elbow flexion.

100%. The disadvantages of using the

shoulder abduction / elevation /

in 79% of their 118 patients receiving

longitudinal incision to approach

the respiratory cycle. In the 3rd

First, the SAN and PN contain more

MPN as neurotizer are the short length

external rotation in upper arm type

SAN-SSN transfers.

the anterior branch (mostly motor

postoperative year, voluntary biceps

motor myelinated fibers than 3 ICNs.

of the donor nerve (MPN), and the long


control is usually obtained, but

Second, the functional relationship

distance between the MPN and MCN

There are several nerve / tendon

2. Triceps branch of radial nerve

space. Subsequently the radial nerve

involuntary elbow contraction while

between shoulder abduction /

which makes its reach to the motor

transfer options for the reconstruction

(TbRN) to axillary nerve (AXN)

is dissected in the triangular interval

coughing and sneezing still persists.

respiration and elbow flexion leads to

branch of the MCN difficult.

of shoulder abduction / elevation /

just distal to the teres major. The motor

Sensory recovery of the MCN territory

easier postoperative rehabilitation.

external rotation in upper arm type

nerve to the long head of the triceps

is also attained. During the first 1 to

However, the SAN-sural nerve graft-

6. Latissimus dorsi (LD) flap / Gracilis

BPI. The donor nerves applied for

is identified and dissected at this

2 years, sensation is perceived only

MCN and PN-sural nerve graft-MCN

free functioning muscle transfer

BPI shoulder function neurotization

point. The TbRN was then coapted by

in the chest. Later, some sensations

methods are purely for motor recovery

(FFMT) to elbow (biceps insertion).

include: spinal accessory nerve

suture to the anterior branch of the

are recovered on the radial surface of

of elbow. No sensory recovery was

These two methods are reserved as

(SAN), triceps branch of radial nerve

AXN directly for restoring the motor

the forearm 2 to 3 years after surgery.

achieved by these 2 techniques. The

salvage procedures for upper arm

(TbRN), medial pectoral nerve (MPN),

function of deltoid muscle. (Figure 6A,

The reported successful rate (≧M3

disadvantages of using the SAN

type BPI reconstruction. In upper

phrenic nerve (PN), and intercostal

6B, 6C) The posterior approach was

elbow flexion) of ICNs neurotization

transfer are the need for harvesting

arm type C5-C6 injury BPI, when the

nerve (ICN). The recipient nerves are

revolutionary because of the ease of

on MCN ranges from 36% to 65%.

sural nerve graft by an additional

above mentioned neurotizations

the suprascapular nerve (SSN) and

Figure 5A: Spinal accessory nerve

dissection, no interpositional graft is

Due to the complexity of harvesting

incision, and the sacrifice of a potential failed, the LD flap anterior transfer

axillary nerve (AXN). The following six

(SAN) and suprascapular nerve (SSN)

required, and it places the donor nerve

ICNs which is a time consuming

neurotizer for a dysfunctional

to biceps tendon insertion (so-called

techniques are the most commonly

were indentified through the anterior

close to the motor endplate of the

procedure, most surgeons prefer

supra-scapular nerve (for shoulder

bipolar transfer) is an alternative

used methods.

supra-clavicular approach.

recipient.47 This type of nerve transfer

Oberlin’s or Mackinnon’s methods for

function). The disadvantages of the PN

salvage procedure for restoring

reconstructing elbow function instead

transfer are similar to the SAN, with

elbow flexion. The successful rate of

1. Spinal accessory nerve (SAN) to

Figure 5B:

and elevation / abduction because this

of ICNs, in upper arm type BPI.

additional drawbacks of immediate

this LD pedicle functioning muscle

suprascapular nerve (SSN) transfer.


method is performed in addition to the

postoperative respiration distress, and

transfer is acceptable (80% ≧M3

The SAN to SSN transfer is an older

was performed

SAN to SSN transfer.2,9,12,15,16,46,47

4. SAN-sural nerve graft-MCN, or PN-

long term complications of decreased

elbow flexion).5 However, in C5-6-7

yet reliable option for restoration of

by SAN to SSN

Leechavengvongs reported that 7 of

sural nerve graft-MCN:

vital capacity of lung function. In

complete injury, the thoracodorsal

shoulder abduction and glenohumeral

transfer, with

7 patients achieved deltoid function

The use of the spinal accessory nerve

recent years, most surgeons prefer

nerve supplying the motor function


9-0 Nylon

against gravity with a mean of 124

(SAN) or phrenic nerve (PN) transfer,

to employ Oberlin’s or Mackinnon’s

of LD muscle is mostly damaged.

XI cranial nerve which serves to


degrees of shoulder abduction. There

by a free sural nerve graft bridging

methods to reconstruct elbow flexion

Therefore, the gracilis FFMT should

innervate the trapezius muscle distally


was no shoulder subluxation or loss

interposition, and neurotization of

in upper arm type BPI, instead of

be employed for reconstructing elbow

in its course. Originally this transfer

the MCN had been reported to have

using the SAN or PN as an elbow

flexion.5,12,40,41 The proximal gracilis

required a large supraclavicular Millesi


Bertelli et al. also reported their

acceptable muscle power recovery


is sutured onto the distal clavicle or

incision for assessment, however

Transferring the radial nerve to the

combined SAN-SSN and TbRN-AXN

coracoid process, while the distal

recent advances in technique have

AXN was originally described in 1948

methods for upper arm type BPI







of elbow flexion (range from 50% to




fibers) of the AXN in the quadrilateral

may improve the shoulder stability


The SAN is the

of triceps function in their series.47

80%≧M3 elbow flexion).

5. Medial pectoral Nerve (MPN) to

gracilis tendon is sutured onto the

permitted much smaller and more

by Alexander Lurje from Russia.

reconstruction in which all patients

A prospective randomized comparison

MCN transfer.

biceps insertion site. The motor nerve

aesthetic incisions.

However, his initial description was

achieved active shoulder abduction

study was conducted to investigate

The direct coaptation suture of the

(obturator nerve) of this FFMT may

has been successful largely due to

through an anterior approach which

/ elevation and external rotation.

the elbow power recovery by SAN-

MPN with the MCN is an intra-plexus

be microsurgically sutured with ICNs

its consistent anatomy, and close

was difficult for surgical dissection,

Abduction recovery averaged 92

nerve graft-MCN and by ICNs-MCN

neurotization method.

or SAN as neurotizers. With adequate

proximity to the donor nerve which

and also had the drawback of requiring

degrees and external rotation averaged

respectively. Their results showed

reported data showed that 80% of

planning of microsurgery and proper

avoids the need for an interpositional

an interpositional nerve graft. This

93 degrees in their patients.14 In






This transfer





May 2016

addition to the posterior approach,

transferred to the anterior branch of

in the Occidental countries because

TbRN-AXN, and Oberlin’s method

Bertelli et al. also described a new

the AXN. The patient is put in supine

of concern regarding decreased

for C5-C6 BPI, were observed to have

6. Trapezius muscle transfer to

approach for TbRN transfer to AXN by

position with a sandbag underneath

pulmonary capacity after the

winging of the scapula, paralysis of

shoulder girdle muscles.

an anterior approach (axillary access)

the affected upper limb. A curved

sacrifice of PN. Based on Gu’s study,

the serratus anterior muscle, and

Persistent shoulder paralysis after

with excellent shoulder recovery (3

incision was made along the 5 rib.

the pulmonary capacity decreased

painful disability when elevating their

BPI is a difficult and challenging

in 3 patients achieved M4 deltoid

To ensure an adequate length of

because of limited excursion and

shoulder. Subsequently, the Lerdsin

problem to treat. Although various

the ICNs, the 4 and 5 ICNs were

elevation of the diaphragm for 1 year,

group developed their method of

methods of neurotizations have been

dissected as far posteriorly as possible.

but then recovered to normal value

reconstruction for serratus anterior

described in the literature, some BPI


function and shoulder abduction).






The advantage of this method is the

Figure 6C: Neurotization with TbRN

Just anterior to the mid-axillary line,

by 2 years postoperatively. Chuang

by transferring the thoracodorsal

patients still suffer from shoulder

ease of dissection through the anterior

transfer to anterior motor branch of

the sensory branches of the ICNs

also frequently used the PN as

nerve to the long thoracic nerve.

dysfunction either after nerve transfer

approach in one surgical position. The

AXN was performed by using 9-0

were identified and cut to enhance

neurotizer for adult patients without

They performed a 12 cm longitudinal

reconstruction failure or delayed /

combined SAN-SSN and TbRN-AXN

Nylon coaptation suture.

the mobility of the ICNs. Then the


significant respiratory problems.

incision along the posterior aspect

neglected treatment. The resulting

shoulder was rolled anteriorly. A

PN transfer to the SSN has similar

of the axilla which was around the

shoulder muscle weakness leads to

second incision was made along the

satisfactory results (around 70% ≧M3

anterior border of the latissimus

a “hand-on-belly” internally rotated

posterior border of deltoid muscle, and

shoulder abduction) as SAN-SSN

dorsi muscle. Retraction of the

position that limits positioning of

3. Intercostal nerves (ICNs) to axillary

the quadrilateral space was explored.

transfer, because the PN has abundant

latissimus dorsi allowed exposure of

the hand anterior to the coronal

nerve (AXN) transfer.

The anterior branch of the AXN

motor fibers. However, patients with

the thoracodorsal and long thoracic

plane with elbow flexion, and painful

Recently many surgeons have

was identified, and a subcutaneous

smoking, poor pulmonary function,

nerves. Two thoracodorsal nerve

glenohumeral subluxation. In these

recommended simultaneous nerve

tunnel was made between the first

associated chest trauma, and morbid

branches (medial and lateral branch)

instances, upper trapezius transfer has

transfer to both the SSN and AXN for

and the second incisions. The 4 and

obesity are not ideal candidates for PN

were identified, and the branch with

been attempted to restore shoulder

achieving better shoulder function.

5 ICNs were passed through the


stronger muscle contraction during

abduction with variable results

nerve stimulation was chosen as the

reported43,44 A combined procedure

method is currently the most popular
technique for shoulder reconstruction

arm type BPI.

in patients with C5-C6 injured upper


Although the SAN to SSN





subcutaneous tunnel and the direct

combined with the TbRN to AXN

coaptation sutured with the anterior

5. Nerve transfer to serratus anterior

neurotizer. The long thoracic nerve

with latissimus dorsi muscle transfer

Figure 6A: Skin marks for Triceps

double neurotization had been

branch of the AXN. Good shoulder

muscle using the thoracodorsal nerve

was exposed along the chest wall

to the greater tuberosity to reconstruct

branch of radial nerve (TbRN) to

reported to have satisfactory results

function with M4 deltoid recovery

for winged scapula.

and divided as proximal as possible

the rotator cuff, and trapezius transfer

axillary nerve (AXN) transfer surgery.

in shoulder recovery, this model of

was obtained in both of their 2

Serratus anterior muscle is one of the

to ensure that the majority of the

to deltoid muscle had been performed

IS (infra-spinatus muscle); Tmi (Teres

double neurotization could not be

patients. Because this is a combined

major scapula stabilizers that is critical

serratus anterior muscle could be

for simultaneous reconstruction of

minor), TMA (Teres major), LD

applied in C5 through C7 root avulsion

procedure with the SAN-SSN and

in maintaining proper scapulohumeral

innervated. This proximal dissection

shoulder abduction / elevation and

(Latissimus dorsi), TL (Triceps long

injuries. In C5,C6 combined with C7

Oberlin procedures, care must be

rhythm during glenohumeral

of long thoracic nerve also provided

external rotation, but the outcomes

head), TLo (Triceps lower head)

damaged BPI, the TbRN could not

taken to ensure adequate length of

movement, particular in shoulder and

enough length of nerve for coaptation

could achieve only around 75

be used as a neurotizer because the

ICNs transfer to the AXN which allows

arm elevation. Patients with serratus

suture without tension. All patients

degrees of shoulder adbuction5,23,25,43,44

main component of the radial nerve

fully passive shoulder abduction

anterior palsy in BPI may present

in their series obtained good shoulder

(Figure 7A, 7B). A novel technique

comes from the C7 root. There are

motion without tension on the nerve

with pain, weakness, limitation of

functional recovery without any donor

of transferring middle and lower

some donor nerves that can be used

coaptation site.

shoulder elevation, and scapular

site complication from harvesting

segments of the trapezius muscle,

winging with medial translation of the

one branch of the thoracodorsal

extended with a tendon allograft,

4. Phrenic nerve (PN) to suprascapular

scapula, rotation of the inferior angle

nerve. This additional neurotization

to restore the external rotation of

the clinical results of PN-AXN, SAN-

nerve (SSN) transfer.

toward the midline, and prominence

procedure (thoracodorsal nerve

shoulder function was reported with

AXN and MPN-AXN neurotization

PN transfer to the SSN could be

of the vertebral border. This winging

transfer to long thoracic nerve) may

good to satisfactory results.44

procedures were unsatisfactory.

performed as a direct neurotization

becomes more prominent as the

offer better shoulder function than the

method for shoulder reconstruction

patient attempts to push forward

combined SAN-SSN and TbRN-AXN

Reconstructions for wrist / hand


for transferring to the AXN, such as
PN, SAN, and MPN.



The Lerdsin group in Thailand


Figure 6B: TbRN (to the long head


of triceps) and anterior branch of

developed a method which uses

without interpositional nerve graft.

against resistance. The Lerdsin group

techniques. This method is especially

extension function in upper arm

AXN can be easily identified in the

the posterior approach to dissect

It has been frequently used by many

in Thailand found that 7 of 15 patients

beneficial in patients who place high

type (C5, C6 with C7 injuries) BPI

quadrilateral space.

the 4 and 5 ICNs which are then

surgeons in Asia, but rarely been used

in their series who received SAN-SSN,

demands on their shoulders.

In upper arm type BPI, many C7







May 2016

not satisfactory. This is because many

full FCU transfer often results in a

PL has been used for thumb extension

Rehabilitation and objective

objective assessment method, which

of the C7 innervated muscles are

slight radial deviation of the hand at

reconstruction, an alternative method

assessment of the motor recovery

employs the use of HHD (Hand-held

located at the forearm level (except

the wrist. If the patient has significant

is using the split FCR, tenodesing it to

after surgery for BPI

dynamometer) for more detailed

the triceps muscles which are located

radial deviation at the wrist, the

both APL (abductor pollicis longus)

Adequate scheduled rehabilitation

and scientific evaluations for the

in the arm level), and hence the re-

insertion of the ECRL (extensor carpi

and EPL tendons.

is the key to satisfactory clinical

functional outcomes of BPI patients

innervation occurs quite slowly before

radialis longus) should be transferred

outcomes after BPI surgery. The

during the rehabilitation program

reaching the target neuromuscular

to the ECU (extenor carpi ulnaris),

Surgical Treatment for Pain

postoperative custom made protecting

after surgery.57,58 This HHD evaluation

junctions. The functional needs of

or the FCU tendon transfer should

Adequate pain management is

brace should be tailored, and each

method has been reported to have

Figure 7A: Delay shoulder

the hand after C7 injury (radial nerve

not be done. Fingers and thumb

mandatory for BPI patients’ quality

patient’s rehabilitation program has to

excellent reliability for measuring

reconstruction with LD (latissimus

palsy) are (1) wrist extension, (2) finger

extension can also be reconstructed

of life. The disability of upper limb

be unique for each injury. The physical

the muscle strength recovery after

dorsi) transfer to anchor at greater

and thumb extension, and (3) thumb

by transferring the FDS (flexor

and intractable pain usually results

therapy with a passive range of motion

neurotization procedures for BPI 57

tuberosity of humeral head that

proximal stability.5 For wrist extension,

digitorum superficialis) tendons of the

in limitation of social activities and

and slow-pulse electrical stimulation

(Figure 8). Based on the objective

served as the rotator cuff function.

the PT (pronator teres) muscle can be

long and ring finger. The ring FDS is

employment. Pain occurs frequently

should be started immediately after

assessment data by HHD evaluations,

transferred to the ECRB (extensor carpi

attached to the EDC, similar to the FCU

after injury, starting usually within

proper surgical wound healing. Home

neurotization in C5-C6 BPI patients

radialis brevis) musculo-tendonious

transfer, and the long FDS is attached

weeks of the trauma event and then

electrical stimulation was provided

had significant better elbow, shoulder,

junction, if the motor function of PT

to the EPL. The other alternative

becomes chronic. Sometimes, but

for all of the patients with a portable

and hand grip functions than C5-6-7

is recovered after BPI reconstruction.

method is transferring the PL to EPL,

not always, the pain may be relieved

slow pulse stimulation device that

BPI patients, which were not detected

For finger extension, the traditional

and transferring the FCR (flexor carpi

by medications, including NSAIDs

the patient was instructed to use for

by simplified MRC grading.58

procedure uses the FCU (flexor carpi

radialis) to the EDC. For the proximal

(Non-steroid anti-inflammatory

4 to 6 hours per day for a minimum

ulnaris) transfer to the EDC (extensor

stability of the thumb, the EPB

drugs), narcotics and anticonvulsants.

of 2 years, or until antigravity motor


digitorum communis) tendons, and

(extensor pollicis brevis) is mobilized

However, many BPI patients suffering

function (M3) occurred. Significant


PL (palmaris longus) transfer to EPL

from the 1st dorsal compartment and

from intractable pain that cannot be

recovery after neurotizations can

treatments for upper arm type BPI

(extensor pollicis longus) tendon. This

tenodesed to the PL. However, when

effectively relieved by pain killers

take more than 9 to 18 months

is close-target neurotization by

muscle transferred was performed,

should be considered as candidates

for functional improvement. The

either intra-plexus neurotization

in combination with the LD-rotator

for surgery. The surgical treatment

rehabilitation programs also include

or extra-plexus neurotization

cuff transfer for reconstructing the

for pain relief may be performed

hand grip-power training (for elbow

methods. The goals are to achieve

shoulder abduction / elevation, and

by the method of DREZ (Dorsal root

neurotization), trapezius muscle

effective elbow flexion, shoulder

external rotation.

entry zone) rhizotomy. The authors

training (for SAN-SSN), respiration

abduction / elevation, and

performed thermocoagulation

training (for ICN-AXN, and PN-SSN),

shoulder external rotation.

injuries are found in combination

(rhizotomy) at the DREZ for intractable

and repeated elbow extension training

with C5 and C6 ruptures. Patients

pain after BPI in 60 cases. Forty cases

(for TbRN-AXN) as well. These

site is still needed for better

are usually presenting with loss

were under regular follow-up for 5 to 18

physical therapy maneuvers may

understanding of the extent of

of shoulder abduction / elevation

years. In the early postoperative stage,

enhance timely motor recovery.

trauma, and for the possibility of

function and elbow flexion, together

the pain relief was excellent or good

The Medical Research Council

identifying available proximal

with loss of wrist and finger

in 32 cases (80%). The pain relief rate

(MRC) grading system, which ranges

nerve root stumps for repairing /

dorsiflexion. The reconstructions for

dropped to 60% at 5 years follow-up,

from grade M0 (no contraction) to


this type of injury may include direct

and only 50% of patients had excellent

M5 (normal), is a quick and easy

repair, nerve graft, and neurotization as

or good pain-relief outcomes in 10

tool to evaluate muscle strength

technique for elbow flexion

well. However, although the reported

years follow-up.

recovery after BPI surgery. However,

(Mackinnon’s method or the

results of good shoulder and elbow

work to be done in treating pain in BPI

the simplified MRC grading system

Oberlin II method) may obtain

function could be obtained after


may result in the underestimation

faster and more effective muscle

Figure 7B: Trapezius to Deltoid



There is still more




The current trends in surgical

Primary exploration of the injury

The double neurotization

various neurotization methods, the

Figure 8: The clinical evaluation of shoulder and elbow muscle power recovery

of muscle strength improvement.

power recovery for elbow flexion

results of C7 functional recovery were

in BPI patients by using the Hand Hold Dynamometer (HHD).

The authors have developed an

than the Oberlin I, ICNs-MCN,




and SAN-sural nerve graft -MCN

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transfers and nerve grafting for

year-old written reference to a

of grafting the anterior and

Shoulder function may be


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Ella Donnison(2)

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Restoration of shoulder function

pectorial nerve: myth or reality?

bamboo in ancient Egyptian times,

More formally known as Additive

also enable surgical teams to plan

with nerve transfers in traumatic

Neurosurgery 2002; 50:1277-82.

to screw-driven metal splints and

Manufacture (AM), 3D Printing is

and practice complex procedures

brachial plexus palsy patients.

54. Bertelli JA, Kechele PR, Santos

low temperature thermoplastics

defined as ‘the process of joining

before an operation to help reduce

Microsurgery 2006; 26: 316-24.

MA, Duarte H, Ghizoni MF.

introduced by European armour

materials to make objects from

the likelihood of potentially fatal

Axillary nerve repair by triceps

makers in the 1960’s. Factors such

3D model data, usually layer

errors occurring (Christensen et al.,

K, Uerpairojkit C, Thuvasethakul

motor branch transfer through an

as polio, war, technological and

upon layer’ (American Society for

2004). From Medicine to Aerospace,

P. nerve transfer to deltoid muscle

axillary access: anatomical basis

surgical advances, education,

Testing and Materials International,

the use of AM is changing the way

using the nerve to the long head

and clinical results. J Neurosurg.

research, government initiatives

2012). AM has gained significant

many industries are working. With

of the triceps, Part II: A report of

2007; 107:370-377.

and professional organizations

public interest in recent years, as

an estimated global advanced

have all played important roles

it can overcome many problems

manufacturing market value of £750

in influencing the development

associated with other forms of

billion by 2020 (UK Commission for

47. Leechavengvongs S, Witoonchart

7 cases. J Hand Surg. 2003; 28(A):


55. Malungpaishorpe K,
Leechavengvongs S, Uerpairojkit