131

C OPYRIGHT Ó 2012 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Hemi-Contralateral C7 Transfer in Traumatic Brachial

Plexus Injuries: Outcomes and Complications
Douglas M. Sammer, MD, Michelle F. Kircher, RN, BSN, Allen T. Bishop, MD,
Robert J. Spinner, MD, and Alexander Y. Shin, MD

Investigation performed at the Mayo Clinic, Rochester, Minnesota

Background: In brachial plexus injuries with nerve root avulsions, the options for nerve reconstruction are limited. In select
situations, half or all of the contralateral C7 (CC7) nerve root can be transferred to the injured side for brachial plexus
reconstruction. Although encouraging results have been reported, CC7 transfer has not gained universal popularity. The
purpose of this study was to critically evaluate hemi-CC7 transfer for restoration of shoulder function or median nerve
function in patients with severe brachial plexus injury.
Methods: A retrospective review of all patients with traumatic brachial plexus injury who had undergone hemi-CC7 transfer
at a single institution during an eight-year period was performed. Complications were evaluated in all patients regardless of
the duration of follow-up. The results of electrodiagnostic studies and modified British Medical Research Council (BMRC)
motor grading were reviewed in all patients with more than twenty-seven months of follow-up.
Results: Fifty-five patients with traumatic brachial plexus injury underwent hemi-CC7 transfer performed between 2001 and
2008 for restoration of shoulder function or median nerve function. Thirteen patients who underwent hemi-CC7 transfer to
the shoulder and fifteen patients who underwent hemi-CC7 transfer to the median nerve had more than twenty-seven months
of follow-up. Twelve of the thirteen patients in the shoulder group demonstrated electromyographic evidence of reinnervation,
but only three patients achieved M3 or greater shoulder abduction motor function. Three of the fifteen patients in the median
nerve group demonstrated electromyographic evidence of reinnervation, but none developed M3 or greater composite grip.
All patients experienced donor-side sensory or motor changes; these were typically mild and transient, but one patient
sustained severe, permanent donor-side motor and sensory losses.
Conclusions: The outcomes of hemi-CC7 transfer for restoration of shoulder motor function or median nerve function
following posttraumatic brachial plexus injury do not justify the risk of donor-site morbidity, which includes possible per-
manent motor and sensory losses.
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

T
raumatic brachial plexus injuries occur in 1% of patients
with polytrauma1. Irreparable preganglionic injury
of multiple spinal nerves (root avulsion injury) is both
common in such individuals and particularly difficult to re-
construct. Neither direct repair nor interpositional nerve graft-
ing can be performed and nerve transfer options are limited,
particularly in patients with complete brachial plexus injury. In
these patients, the donor nerves from outside the brachial plexus
that are most commonly used in brachial plexus reconstruction
include the spinal accessory nerve, the intercostal nerves, and in
some situations the phrenic nerve. When these commonly used
extraplexal donor nerves are not sufficient to reconstruct the
brachial plexus and restore needed function, all or half of the
uninjured contralateral C7 (CC7) nerve root may be transferred
to the injured side with use of nerve grafting to provide a source
of viable axons.
The CC7 transfer technique was introduced by Gu et al. in
19912, and it may be used for a variety of purposes3-12: to restore

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2012;94:131-7 d http://dx.doi.org/10.2106/JBJS.J.01075

 132
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 94-A N U M B E R 2 J A N UA R Y 18, 2 012
d d
motor or sensory function in the hand (median nerve function),
elbow flexion3,6,8,10-12, and shoulder function. In addition, CC7
transfer has been used to power a functional free muscle. Al-
though a number of groups have reported performing brachial
plexus reconstruction using CC7 transfer3,6,8,10-12, the results have
been variable. Common concerns include donor-site morbidity,
a poor rate of recovery of distal extremity function, and inability
to control contralateral muscles independently. The purpose of
the present study was to critically evaluate the outcomes and
complications of hemi-CC7 transfer performed for restoration
of shoulder function or median nerve function.
Materials and Methods
A fter institutional review board approval, a retrospective review of post-
traumatic brachial plexus injuries treated at a single institution from 2001
through 2008 was undertaken. Fifty-five patients with traumatic brachial plexus
injury who had undergone hemi-CC7 transfer were identified and included in
the study. Complications and donor-site morbidity were recorded for all fifty-
five patients. Reconstructive outcomes were evaluated only in the twenty-eight
patients with more than twenty-seven months of postoperative follow-up that
included both electromyography and physical examination. Thirteen of these
patients had hemi-CC7 transfer for restoration of shoulder function, and the
other fifteen had hemi-CC7 transfer to the median nerve.
In the patients who had undergone hemi-CC7 transfer for restoration of
shoulder function, objective outcome measurements included postoperative
electromyographic results and a modification of the British Medical Research
13,14
Council (BMRC) motor grading of shoulder abduction and external rotation .
Electromyography of the deltoid muscle was performed in patients who had
undergone nerve transfer to the axillary nerve, and electromyography of the
supraspinatus and/or infraspinatus muscles was performed in patients who had
undergone nerve transfer to the suprascapular nerve. The latest of the serial
electromyographic examinations is reported in this study. Motor grading of
shoulder abduction was measured as global shoulder abduction. Motor grading
of external rotation was measured with the elbow flexed 90° and the arm fully
adducted to the patient’s side. A particular motor grade was assigned only if the
patient was able to actively move the joint through its full passive arc of motion
(Table I). For example, if the patient could abduct the shoulder through its full
passive arc of motion with gravity eliminated but could only abduct the shoulder
against gravity through part of that arc of motion, a motor grade of M2 (not M3)
was assigned.
In the patients who had undergone hemi-CC7 transfer to the median
nerve, objective outcome measurements included postoperative electromyo-
graphic results and BMRC grading of composite grip. Electromyography of the
pronator teres muscle was performed in all patients who had undergone hemi-
CC7 transfer to the median nerve, and electromyography of other extrinsic
flexor muscles innervated by the median nerve was performed in selected
patients. The latest of the serial electromyography examinations is reported in
this study. A particular motor grade was assigned only if the patient was able to
move the fingers through their full passive arc of flexion during the attempted
composite grip. For example, if the patient could flex the fingers along their full
passive arc of motion against gravity but could only provide resistance along
part of that arc of motion, a motor grade of M3 (not M4) was assigned.
Surgical Technique
The technique for dissection and division of the CC7 nerve followed by its
transfer to the injured brachial plexus by means of conventional or vascularized
6,8,11,12,15-17
nerve grafting has been well described in the literature . In the pre-
sent study, all patients underwent hemi-CC7 transfer, with preservation of the
other half of the CC7 nerve. After identification and dissection of the CC7 nerve
and middle trunk, the nerve sheath was divided longitudinally, exposing the
fascicles. Direct fascicular electrical stimulation was performed, allowing
identification and division of the portion of the nerve that provided primarily
H E M I -C O N T R A L AT E R A L C7 T R A N S F E R IN T R AU M AT I C
BRACHIAL PLEXUS INJ URI ES
TABLE I Motor Grading System*
Grade Motor Activity
M0 No contraction
M1 Palpable or visible contraction
M2 Full range of motion with gravity eliminated
M3 Full range of motion against gravity
M4 Full range of motion against resistance,
but with decreased strength
M5 Normal
*Modification of the British Medical Research Council system
13,14
.
shoulder adduction through pectoralis muscle contraction. The portions of
the nerve providing wrist and hand motion were preserved. In most cases, the
anterosuperior half of the nerve was divided and transferred. A subcutaneous
tunnel was used for passage of the nerve graft or grafts in all cases.
In the shoulder group, the hemi-CC7 nerve was transferred end-to-end
to the axillary nerve and/or the suprascapular nerve with use of reversed
nonvascularized sural-nerve cable grafts. In most cases, two sural nerve grafts
were used, one to the suprascapular nerve and the other to the axillary nerve.
The hemi-CC7 transfer to the shoulder was performed in patients in whom
standard transfers, such as transfer of the spinal accessory nerve to the supra-
scapular nerve, were not feasible or in whom the spinal accessory nerve was
used for another purpose such as innervating a free functioning muscle transfer.
Although hemi-CC7 transfer can constitute one part of a larger brachial plexus
reconstruction, no other nerve grafts or nerve transfers were performed in these
patients to restore shoulder function.
In the median nerve group, the hemi-CC7 nerve was transferred to the
median nerve with use of a pedicled vascularized ulnar nerve graft based on
the superior ulnar collateral vessels. The nerve was transferred end-to-end to
the entire cross-sectional area of the median nerve, with the goal of restoring
both sensory and motor function to the hand. No other nerve grafts or nerve
transfers were performed in these patients to restore median nerve function.
In all but one patient, the hemi-CC7 transfer was performed during the
initial surgical procedure for brachial plexus reconstruction. In the remaining
patient, the hemi-CC7 transfer was performed during a second stage. All pa-
tients were treated postoperatively by a hand therapist experienced in brachial
plexus reconstruction therapy. Initial therapy focused on maintaining passive
motion in the recipient extremity. As soon as clinical or electrodiagnostic ev-
idence of reinnervation was present, the patient was instructed in activation of
the transfer by contracting the C7-innervated motor muscles of the contra-
lateral side. Biofeedback was also used to assist in activating the transfer.
Source of Funding
No source of external funding was used for any aspect of this study.
Results
T he characteristics of the patients in the shoulder and me-
dian nerve groups with more than twenty-seven months of
follow-up are summarized in Table II. Most patients had sus-
tained a complete brachial plexus injury. In the shoulder group,
eleven of the thirteen patients had a complete plexus injury,
one patient had sparing of C8 and T1, and one patient had
sparing of T1. In the median nerve group, fourteen of the
fifteen patients had a complete plexus injury and one patient
had partial sparing of C5 and C6. The hemi-CC7 transfers that
 133
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
H E M I -C O N T R A L AT E R A L C7 T R A N S F E R IN T R AU M AT I C
V O L U M E 94-A N U M B E R 2 J A N UA R Y 18, 2 012
d d
BRACHIAL PLEXUS INJ URI ES

was at a mean of forty months postoperatively (range, twenty-

TABLE II Characteristics of the Patients with More Than seven to sixty-six months).
Twenty-seven Months of Follow-up
Three of the fifteen patients demonstrated electromyo-
Shoulder Median Nerve graphic evidence of motor reinnervation of the pronator teres
Group Group muscle or other extrinsic flexor muscles innervated by the
median nerve (Table IV). No patient achieved a functional (M3
No. of patients
or greater) composite grip (Table IV). None of the patients who
Total 13 15
had activation of the median nerve muscles had independent
Male 11 14
control (without activation of the contralateral muscles in-
Less than 18 years of age 4 2
nervated by the CC7 nerve).
Tobacco use 2 2
Right hand dominant† 12 14
Complications and Donor-Side Morbidity
Dominant side injury† 5 9
All fifty-five patients were evaluated for complications and
Blunt trauma 13 15
donor-side morbidity; the mean duration of postoperative
Age* (yr) 25 (14-34) 27 (10-46) follow-up was sixteen months (range, two to sixty-six months).
Mean body mass 25 27 All patients reported subjective alterations in sensibility in the
index (kg/m2) C7 distribution on the donor side immediately after surgery.
Time from injury to 135 (53-215) 159 (50-297) In fifty-three patients, these sensory changes were mild and
operating room* (d) improved within six months. However, donor-side two-point
discrimination remained abnormal (>8 mm) at the time of the
*The values are given as the mean, with the range in parentheses. latest follow-up in the remaining two patients. One of these
†One patient in each group had unknown hand dominance.
patients had 9-mm two-point discrimination at the time of
the latest follow-up two years postoperatively. This was not
were performed in each group are summarized in Table III, and associated with pain and was not bothersome to the patient.
the other brachial plexus procedures that were performed are The second patient had 15-mm two-point discrimination at
reported in the Appendix. the time of the latest follow-up ten months postoperatively, and
the sensory loss was associated with neuropathic pain. One
Shoulder Group other patient who did not have prolonged changes in two-point
Thirteen patients had more than twenty-seven months of discrimination after hemi-CC7 harvesting also had severe
postoperative follow-up that included both electromyography neuropathic pain. The neuropathic pain in both patients was
and physical examination. Electromyography and physical managed successfully with non-narcotic analgesics. Seventeen
examination were not always performed at the same postoper- patients had mild transient donor-side triceps weakness re-
ative visit. The most recent electromyography was at a mean of sulting from the hemi-CC7 transfer that spontaneously re-
thirty-two months postoperatively (range, twenty-seven to fifty- solved over a period of three to five months. The patient with
three months), and the most recent physical examination was at 15-mm two-point discrimination sustained profound, per-
a mean of thirty-three months postoperatively (range, twenty- manent donor-side motor as well as sensory losses after sur-
seven to sixty-five months). gery; motor deficits on the donor side included grade-M2 to
Twelve of the thirteen patients demonstrated electro-
myographic evidence of motor reinnervation of one or more of
the target muscles (Table IV). Three of the thirteen patients TABLE III Nerve Grafting Procedures
achieved functional (M3 or greater) shoulder abduction (Table
No.
IV); the mean abduction in the entire group was 10° (range, 0°
to 60°). No patient demonstrated active external rotation of the Shoulder group
shoulder. Furthermore, none of the patients who had activation Recipient nerves Both suprascapular 11
of the muscles in the injured shoulder had independent control and axillary
(without activation of the contralateral muscles innervated by Axillary only 2
the CC7 nerve).
Type of nerve graft Nonvascularized reversed 13
sural autograft
Median Nerve Group
Fifteen patients had more than twenty-seven months of post- Median nerve group
operative follow-up that included both electromyography and Recipient nerves Median only 14
physical examination. Electromyography and physical exami- Median and musculocutaneous 1
nation were not always performed at the same postoperative Type of nerve graft Pedicled vascularized ulnar 14
visit. The most recent electromyography was at a mean of nerve graft
thirty-two months postoperatively (range, twenty-seven to Nonvascularized graft 1
sixty-five months), and the most recent physical examination
 134
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 94-A N U M B E R 2 J A N UA R Y 18, 2 012
d d
TABLE IV EMG Results and Modified BMRC Motor Grades*
Shoulder Median Nerve
No. of Patients Group (no.) Group (no.)
Total 13 15
EMG evidence of 12† 3 without activation of contralateral C7-innervated muscles.
reinnervation†
Motor grade‡
M0 2 12
M1 6 2
M2 2 1
M3 2 0
M4 1 0
M5 0 0
*In patients with more than twenty-seven months of follow-up.
EMG = electromyography, and BMRC = British Medical Research
Council. †Reinnervation of deltoid (axillary nerve) and supraspi-
natus or infraspinatus (suprascapular nerve) in six patients, re-
innervation of deltoid only (axillary nerve) in five patients, and
reinnervation of supraspinatus or infraspinatus only (suprascap-
ular nerve) in one patient. ‡Shoulder abduction in the shoulder
group or composite grip in the median nerve group.
M3 weakness in the median and ulnar nerve distributions in
the hand, including loss of intrinsic and thenar function, and
loss of flexor digitorum profundus and flexor digitorum su-
perficialis function. This patient required subsequent tendon
transfers on the donor side. One patient developed a keloid
at the donor-site scar. Two patients requested and underwent
elective transhumeral amputation of the injured extremity (the
recipient side) after recovering from the brachial plexus re-
construction because of persistent loss of sensibility and motor
function.
Discussion
T here are a number of potential advantages to the use of the
CC7 nerve as a source of axons for brachial plexus re-
construction. The C7 nerve contains over 25,000 myelinated
fibers, which far outnumbers that in other nerves that are
frequently used for transfers in brachial plexus reconstruc-
tion7,18. In addition, the C7 nerve contains a large number of
both sensory and motor axons, making it suitable for recon-
struction of motor nerves such as the suprascapular nerve and
of complex sensory and motor nerves such as the median
nerve. In spite of the large number of axons, there is little
reported donor-side morbidity following division of the C7
nerve3,6,8,10,11. Symptoms usually include mild or subclinical
sensory or motor alterations that typically resolve spontane-
ously within a few months. Additionally, there is some evidence
that cortical control of the transferred portion of the CC7 nerve
shifts to the opposite motor cortex over time19-23, allowing more
natural use of the CC7-innervated muscles. In spite of these
substantial advantages and the increasing acceptance of the
CC7 nerve transfer, however, there is persistent concern re-
garding potential donor-side morbidity and suboptimal inde-
H E M I -C O N T R A L AT E R A L C7 T R A N S F E R IN T R AU M AT I C
BRACHIAL PLEXUS INJ URI ES
pendent functionality, leading to concern that the potential
benefits of CC7 nerve transfer may not justify the risks10.
The results of hemi-CC7 transfer to the shoulder in the
present study were disappointing, with only three of thirteen
patients achieving a grade of M3 or greater for shoulder ab-
duction and no patient achieving independent motor control
There are few previous reports of complete or hemi-CC7
transfer to the shoulder with which the results of the present
study can be compared. Hentz and Doi reported the results of
a series of eight CC7 transfers, two of which were to the su-
prascapular nerve15. The latter two patients achieved M2 and M3
shoulder function. In 2006, Terzis et al. reported the results of
a series of brachial plexus reconstructions to restore shoulder
function, five of which included partial CC7 transfer to the ax-
illary nerve24. However, in addition to the CC7 transfer, these
patients also underwent spinal accessory nerve transfer to the
suprascapular nerve, making it impossible to evaluate the results
of the CC7 transfer in isolation. More recently, in 2009, Terzis
and Kokkalis reported the results of a large series of partial
CC7 transfers for brachial plexus reconstruction, ten of which
were to the axillary nerve25. Only 20% of the patients who un-
derwent nerve transfer to the axillary nerve achieved good
results (a grade of M31 or greater for the deltoid according to
a modified BMRC grading scale)25,26. However, as in the prior
study, these patients also underwent other ipsilateral nerve
transfers, making it difficult to isolate the effect of the CC7
transfer on shoulder function. These results suggest that there
is little evidence that hemi-CC7 transfer alone effectively re-
stores shoulder function in this patient population.
The results of hemi-CC7 transfer to the median nerve in
the present study were also poor, with no patients achieving a
functional hand grip. In the literature, the rate of recovery of
grade-M3 or greater motor function following CC7 recon-
struction of the median nerve has ranged from 20% to 50%. In
2002, Gu et al.6 reported the results of thirty-two CC7 transfers,
fourteen of which were used to innervate the median nerve.
Seven (50%) of these fourteen patients achieved at least grade-
M3 recovery of median nerve function. In 2001, Songcharoen
et al.11 reported the long-term results of twenty-one hemi-CC7
transfers to restore median nerve function. Six (29%) of these
patients developed at least grade-M3 recovery of wrist and finger
flexor function. Subsequently, Hierner and Berger10 reported the
results of ten hemi-CC7 transfers, four of which were to the
median nerve. A functional ‘‘primitive’’ grip was achieved in one
(25%) of the four patients at eighteen months postoperatively.
Most recently, Terzis et al. reported the results of a series of fifty-
six partial CC7 transfers for posttraumatic brachial plexus re-
construction, twenty-nine of which involved transfer to the
median nerve25,27. Ten (34%) of these twenty-nine patients
demonstrated grade-M31 or greater wrist and finger flexion25,27
according to a modified BMRC grading scale26.
Many factors can affect the outcome of a CC7 transfer.
Motor outcomes are likely related to the number of motor
fibers included in the transfer, which is determined in part by
whether a complete or a hemi-CC7 transfer is performed. In
 135
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 94-A N U M B E R 2 J A N UA R Y 18, 2 012
d d
the present study, one-half of the CC7 nerve was transferred,
and this may have affected the outcome. Gu et al. advocated
transferring the entire CC7 nerve and attributed the favorable
results in their patients in part to this practice6,7,18. However,
other groups have preferentially performed hemi-CC7 trans-
fers with relative success11,25,27. In the present study, the decision
to perform a hemi-CC7 transfer instead of a complete CC7
transfer was made in an effort to limit the risk of donor-site
morbidity, and this decision was supported by the promising
outcomes reported by other groups who had performed hemi-
CC7 transfers.
When a hemi-CC7 transfer is performed, the portion of
the CC7 nerve that is divided and transferred may affect out-
comes as well. The posterior portion of the C7 nerve contains
twice as many motor fibers as the anterior portion, and some
authors have advocated transferring the posterior half of the
nerve preferentially7,18. In the present study, the anterosuperior
half of the nerve was transferred in order to avoid downgrading
donor-side hand function, and this may have affected motor
outcomes in the recipient extremity. However, other authors
have reported successful reconstruction using the anterior
portion of the CC7 nerve, particularly for transfer to the me-
dian nerve25,27.
Another factor that may affect outcomes is the routing of
the nerve grafts. Although the nerve grafts in the present study
were routed through an anterior subcutaneous tunnel, an al-
ternative prespinal (retropharyngeal) route has also been pro-
posed and used clinically28,29. The prespinal route decreases the
distance between the CC7 donor axons and their target but
introduces additional risks related to the surgical technique.
However, the clinical importance of this modification has not
been demonstrated, and most groups continue to use an an-
terior subcutaneous tunnel.
One factor that may specifically affect the outcome of
CC7 transfer to the median nerve is the staging of the CC7
transfer. In the present study, all hemi-CC7 transfers to the
median nerve were performed in a single stage using a pedicled
vascularized ulnar nerve graft. An experimental study by Lao
et al.30 suggested that staged transfer of the CC7 nerve results in
optimal recovery because of improved blood supply to the
pedicled nerve graft. However, this has not been consistently
borne out in human studies, and other groups have reported
successful reconstruction in a single stage11,25,27.
Other factors that influence the outcome of CC7 nerve
transfer include patient age and the time from injury to surgery.
Gu et al. reported better results in patients younger than 40
years of age and in patients who underwent CC7 nerve transfer
within one year of injury8. Waikakul et al.12 reported signifi-
cantly and substantially better motor function in patients
eighteen years of age or younger. Terzis et al. also reported
significantly better outcomes in patients younger than eighteen
years of age and in patients who underwent CC7 transfer
within nine months of injury25,27. In our series, six patients were
ten to fourteen years of age and the remaining forty-nine were
eighteen years of age or older. Other factors such as body mass
index and arm length may affect functional outcomes as well.
H E M I -C O N T R A L AT E R A L C7 T R A N S F E R IN T R AU M AT I C
BRACHIAL PLEXUS INJ URI ES
Finally, the methods that are used to grade motor func-
tion and to measure joint motion can affect apparent out-
comes. A strict modification of the BMRC grading system was
used in the present study (Table I). In order to receive a par-
ticular grade, the patient must demonstrate strength adequate
to receive that grade throughout their full passive arc of mo-
tion. For example, a patient who is able to flex the fingers
through their full passive arc of motion against gravity but who
can flex against resistance along only part of that arc would
receive a grade of M3 (not M4). How motion is measured is
important as well, particularly in the shoulder. Malessy et al.31
emphasized the importance of distinguishing between true
glenohumeral abduction and shoulder abduction that is sec-
ondary to scapulothoracic rotation. Lateral flexion of the spine
can also result in the appearance of shoulder abduction. The
accurate measurement of external rotation at the shoulder is
also essential to assess the outcome of surgery. From a func-
tional standpoint, external rotation may be more important
than shoulder abduction, since it is required for positioning the
hand in front of the body for functional activities. Malessy
et al.31 emphasized that, as with abduction, scapulothoracic
rotation can contribute to apparent external rotation. In the
present study, global shoulder abduction (as opposed to iso-
lated glenohumeral abduction) was measured. Because of this,
some of the shoulder abduction demonstrated by the patients
in the present study can likely be attributed to factors other
than the hemi-CC7 nerve transfer.
Patients in the present study generally experienced mild,
temporary donor-side sensory or motor changes similar to those
described in the literature. However, one patient had severe
donor-side motor and sensory losses; it is unclear whether this
occurred secondary to technical error or anatomic variation. The
reported prevalence of sensory changes has ranged from ap-
proximately 50% to 100%4,11,32, whereas the prevalence of clinical
motor deficits has ranged from <5% to >20%4,9,11,12. In 1998,
Chuang et al.4 reported the results of twenty-one CC7 transfers,
most of which involved division and transfer of the entire nerve,
after at least two years of follow-up. A majority (52%) of the
patients reported subjective sensory changes that included
numbness and paresthesias primarily affecting the volar aspect
of the index, thumb, and long fingers. Most patients experienced
improvement of these symptoms within a month, with the ex-
ception of one patient who had symptoms that persisted for
sixteen months. In spite of the subjective sensory changes, the
results of two-point discrimination and monofilament sensory
threshold testing were within normal limits at two weeks post-
operatively. In the same study, 19% of patients noticed motor
weakness (grade M2 to M4) after the CC7 transfer. This motor
weakness most often involved the triceps or extrinsic finger
extensor muscles and most often improved within two months.
Although relatively few patients in the study by Chuang et al. had
clinical weakness, LIDO (Loredan Biomedical, Sacramento,
California) workstation testing detected subclinical weakness on
the donor side in 100% of the patients. These subclinical deficits
tended to improve after six months. It should be noted that
severe donor-side motor deficits are rare but that they do occur.
 136
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 94-A N U M B E R 2 J A N UA R Y 18, 2 012
d d
Songcharoen et al.11 analyzed the adverse events in 111 patients
who underwent hemi-CC7 transfer. One patient developed se-
vere donor-side weakness (grade M2). The motor deficit was
isolated to the extensor digitorum communis muscle and im-
proved spontaneously to grade M4 over a three-year period. In
the study by Chuang et al.4, one patient had motor deficits that
lasted for two years.
The present study has a number of limitations, including
those inherent in retrospective chart analysis. Some aspects of
the patient records were incomplete, and not all patients re-
turned for postoperative follow-up at the same intervals. The
exact lengths of the sural nerve grafts and vascularized ulnar
nerve grafts were not known. Data regarding sensory recovery
on the injured side after nerve transfer to the median nerve, an
important outcome parameter, were usually not available and
were therefore not reported in this study. Another limitation is
the long time required for recovery after brachial plexus injury
and reconstruction. As a result, only about approximately one-
half of the patients who underwent CC7 transfer at our insti-
tution had a sufficiently long follow-up to reasonably evaluate
the motor results of the transfer. A minimum duration of follow-
up of twenty-seven months postoperatively was chosen because
it is past the time at which motor recovery ceases to be possible
because of motor end-plate fibrosis33. However, some authors
have suggested that an even longer follow-up period of more
than five years is necessary to determine whether adequate
function and independent function have been achieved6,8,12.
Another limitation involves the BMRC grading scale itself, which
has been revised and modified many times and by multiple
References
1. Midha R. Epidemiology of brachial plexus injuries in a multitrauma population.
Neurosurgery. 1997;40:1182-9.
2. Gu YD, Zhang GM, Chen DS, Cheng XM, Zhang LY, Yan JG, Cai PQ, Shen LY.
Cervical nerve root transfer from contralateral normal side for treatment of brachial
plexus root avulsions. Chin Med J (Engl). 1991;104:208-11.
3. Chen L, Gu YD, Hu SN, Xu JG, Xu L, Fu Y. Contralateral C7 transfer for the
treatment of brachial plexus root avulsions in children - a report of 12 cases. J Hand
Surg Am. 2007;32:96-103.
4. Chuang DC, Cheng SL, Wei FC, Wu CL, Ho YS. Clinical evaluation of C7 spinal
nerve transection: 21 patients with at least 2 years’ follow-up. Br J Plast Surg.
1998;51:285-90.
5. Doi K, Hattori Y, Ikeda K, Dhawan V. Significance of shoulder function in the
reconstruction of prehension with double free-muscle transfer after complete pa-
ralysis of the brachial plexus. Plast Reconstr Surg. 2003;112:1596-603.
6. Gu Y, Xu J, Chen L, Wang H, Hu S. Long term outcome of contralateral C7 transfer:
a report of 32 cases. Chin Med J (Engl). 2002;115:866-8.
7. Gu YD. Contralateral C7 root transfer over the last 20 years in China. Chin Med J
(Engl). 2007;120:1123-6.
8. Gu YD, Chen DS, Zhang GM, Cheng XM, Xu JG, Zhang LY, Cai PQ, Chen L. Long-term
functional results of contralateral C7 transfer. J Reconstr Microsurg. 1998;14:57-9.
9. Gu YD, Zhang GM, Chen DS, Yan JG, Cheng XM, Chen L. Seventh cervical nerve
root transfer from the contralateral healthy side for treatment of brachial plexus root
avulsion. J Hand Surg Br. 1992;17:518-21.
10. Hierner R, Berger AK. Did the partial contralateral C7-transfer fulfill our expec-
tations? Results after 5 year experience. Acta Neurochir Suppl. 2007;100:33-5.
11. Songcharoen P, Wongtrakul S, Mahaisavariya B, Spinner RJ. Hemi-contralateral
C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury.
J Hand Surg Am. 2001;26:1058-64.
12. Waikakul S, Orapin S, Vanadurongwan V. Clinical results of contralateral C7 root
neurotization to the median nerve in brachial plexus injuries with total root avulsions.
J Hand Surg Br. 1999;24:556-60.
H E M I -C O N T R A L AT E R A L C7 T R A N S F E R IN T R AU M AT I C
BRACHIAL PLEXUS INJ URI ES
groups since its original description, and which remains a rela-
tively gross assessment of strength. A more precise method of
grading motor function, such as LIDO or CYBEX (Medway,
Massachusetts) workstation testing, would have been beneficial.
On the basis of the outcomes in this study, the authors do
not support the use of hemi-CC7 transfer alone for either
restoration of shoulder function or transfer to the median
nerve in patients with posttraumatic brachial plexus injury.
Appendix
A table listing the other procedures performed in the pa-
tients with more than twenty-seven months of follow-up is
available with the online version of this article as a data sup-
plement at jbjs.org. n
Douglas M. Sammer, MD
Department of Plastic Surgery,
University of Texas Southwestern Medical Center,
1801 Inwood Road, Dallas, TX 75390
Michelle F. Kircher, RN, BSN
Allen T. Bishop, MD
Robert J. Spinner, MD
Alexander Y. Shin, MD
Departments of Orthopedic Surgery (M.F.K., A.T.B., and A.Y.S.)
and Neurosurgery (R.J.S.), Mayo Clinic,
200 First Street S.W., Rochester, MN 55905.
E-mail address for A.Y. Shin: shin.alexander@mayo.edu
13. Medical Research Council. Aids to the investigation of peripheral nerve injuries.
2nd ed. London: Her Majesty’s Stationery Office; 1943.
14. Seddon HJ, editor. Peripheral nerve injuries. Medical Research Council Special
Report Series No. 282. London: Her Majesty’s Stationery Office; 1954.
15. Hentz VR, Doi K. Traumatic brachial plexus injury. In: Green DP, Hotchkiss RN,
Pederson WC, Wolfe SW, editors. Green’s operative hand surgery. 5th ed. Phila-
delphia: Elsevier; 2005. p 1319-71.
16. Xu J, Gu Y, Lao J, Cheng X, Dong Z. Anatomic basis of vascularized ulnar nerve
graft by the pedicle of the superior collateral ulnar artery. Chin J Traumatol. 2001;
4:195-8.
17. Xu W, Lu J, Xu J, Gu Y. Full-length ulnar nerve harvest by means of endoscopy for
contralateral C7 nerve root transfer in the treatment of brachial plexus injuries. Plast
Reconstr Surg. 2006;118:689-95.
18. Xu JG, Hu SN, Wang H, Gu YD. Histochemical study on C7 roots and its clinical
significance. Chin J Clin Anat. 1996;14:243-5.
19. Li WJ, Gu YD, Liu HQ, Xu WD, Li JF. Functional MRI study on changes of cross-
hemispherical brain plasticity following contralateral C7 transfer. Chin J Hand Surg.
2005;21:252-5.
20. Li ZY, Xu JG, Xu WD, Gu YD. Electrophysiological study on changes of
plasticity of bilateral primary somatosensory cortex following total brachial
plexus root avulsion injuries in adult rats. Chin J Hand Surg. 2005;21:362-4.
21. Li ZY, Xu WD, Xu JG, Gu YD. Experimental study on changes of plasticity of
contralateral motor cortex following total brachial plexus root avulsion injuries in the
adult rats. Chin J Hand Surg. 2004;20:51-4.
22. Lou L, Gu YD, Shou TD. Dynamically functional reorganization in somatosensory
cortex induced by the contralateral peripheral nerve transfer to an injured arm. Prog
Biochem Biophys. 2006;33:17-23.
23. Lou L, Shou T, Li Z, Li W, Gu Y. Transhemispheric functional reorganization of
the motor cortex induced by the peripheral contralateral nerve transfer to the injured
arm. Neuroscience. 2006;138:1225-31. Epub 2006 Jan 19.
 137
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 94-A N U M B E R 2 J A N UA R Y 18, 2 012
d d
24. Terzis JK, Kostas I, Soucacos PN. Restoration of shoulder function with nerve
transfers in traumatic brachial plexus palsy patients. Microsurgery. 2006;26:
316-24.
25. Terzis JK, Kokkalis ZT. Selective contralateral c7 transfer in posttraumatic
brachial plexus injuries: a report of 56 cases. Plast Reconstr Surg. 2009;123:
927-38.
26. Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus recon-
struction in 204 patients with devastating paralysis. Plast Reconstr Surg. 1999;
104:1221-40.
27. Terzis JK, Kokkalis ZT, Kostopoulos E. Contralateral C7 transfer in adult plexop-
athies. Hand Clin. 2008;24:389-400, vi.
28. Mcguiness CN, Kay SP. The prespinal route in contralateral C7 nerve root
transfer for brachial plexus avulsion injuries. J Hand Surg. 2002;27:159-60.
H E M I -C O N T R A L AT E R A L C7 T R A N S F E R IN T R AU M AT I C
BRACHIAL PLEXUS INJ URI ES
29. Xu L, Gu Y, Xu J, Lin S, Chen L, Lu J. Contralateral C7 transfer via the prespinal
and retropharyngeal route to repair brachial plexus root avulsion: a preliminary re-
port. Neurosurgery. 2008;63:553-8.
30. Lao J, Xiong LJ, Gu YD, Mang YH. Optimal time of contralateral side C7 root transfer for
brachial plexus root avulsion: an experimental study. Chin J Hand Surg. 1995;11:165-7.
31. Malessy MJ, de Ruiter GC, de Boer KS, Thomeer RT. Evaluation of suprascap-
ular nerve neurotization after nerve graft or transfer in the treatment of brachial
plexus traction lesions. J Neurosurg. 2004;101:377-89.
32. Sungpet A, Suphachatwong C, Kawinwonggowit V. Sensory abnormalities after
the seventh cervical nerve root transfer. Microsurgery. 1999;19:287-8.
33. Gorio A, Carmignoto G. Reformation, maturation and stabilization of neuromuscular
junctions in peripheral nerve regeneration. In: Gorio A, Millesi H, Mingrino S, editors.
Posttraumatic peripheral nerve regeneration. New York: Raven Press; 1981. p 481-92.