http://jhs.sagepub.com European Volume) Journal of Hand Surgery (British and DOI: 10.1054/JHSB.1999.0264 1999; 24; 556 Journal of Hand Surgery (British and European Volume) S. WAIKAKUL, S. ORAPIN and V. VANADURONGWAN Injuries with Total Root Avulsions Clinical Results of Contralateral C7 Root Neurotization to the Median Nerve in Brachial Plexus http://jhs.sagepub.com/cgi/content/abstract/24/5/556 The online version of this article can be found at: Published by: http://www.sagepublications.com On behalf of: British Society for Surgery of the Hand Federation of the European Societies for Surgery of the Hand can be found at: Journal of Hand Surgery (British and European Volume) Additional services and information for http://jhs.sagepub.com/cgi/alerts Email Alerts: http://jhs.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: © 1999 The British Society for Surgery of the Hand. All rights reserved. Not for commercial use or unauthorized distribution. by on July 30, 2008 http://jhs.sagepub.com Downloaded from CLINICAL RESULTS OF CONTRALATERAL C7 ROOT NEUROTIZATION TO THE MEDIAN NERVE IN BRACHIAL PLEXUS INJURIES WITH TOTAL ROOT AVULSIONS S. WAIKAKUL, S. ORAPIN and V. VANADURONGWAN From the Siriraj Hospital, Mahidol University, Bangkok, Thailand This prospective study was carried out to assess motor and sensory recovery after contralateral C7 root to median nerve neurotization in brachial plexus injuries with total root avulsions. The survey was carried out from 1993 to 1995 and the patients were followed up for at least 3 years. There were 96 male patients with ages ranging from 13 to 48 years. All had a unilateral brachial plexus injury with avulsion of all roots. This was con®rmed by clinical assessment and exploration. The anterior part of the contralateral C7 root was used for neurotization via a reversed pedicular ulnar nerve graft and the proximal end of the graft was connected to the median nerve. Furthermore, phrenic nerve to suprascapular nerve and spinal accessory nerve (via a sural nerve graft) to musculocutaneous nerve neurotizations were also carried out to obtain shoulder abduction and elbow ¯exion. At the 3 year follow-up, most patients had encouraging recovery of sensory function in the hand but motor function of the forearm and hand muscles was rather poor. Acceptable motor function was found in only 50 to 60% of the patients who were younger than 18 years. Journal of Hand Surgery (British and European Volume, 1999) 24B: 5: 556±560 Neurotization or nerve transfer is now a common procedure for motor and sensory reconstruction in brachial plexus injuries with root avulsions. The ipsilateral donor nerves, such as the spinal accessory, intercostal and phrenic nerves, have fewer nerve ®bres than the major nerves of the brachial plexus. Therefore, the results of neurotization have been very limited in terms of motor and sensory function (Narakas and Hentz, 1988). The contralateral C7 root, which contains many more nerve ®bres than ipsilateral donor nerves, has been used for neurotization with very encouraging results, both in experimental and clinical studies (Chen and Gu, 1994; Gu et al. 1998). The morbidity of using C7 as a donor has been very low and no permanent neurological de®cit was observed (Gu, 1994; Gu and Shen, 1994). The aim of this study was to determine the clinical results when the contralateral C7 root was used for neurotization of the median nerve with ulnar nerve grafting in brachial plexus injuries with complete avulsion of the roots. PATIENTS AND METHODS The study was carried out between 1993 and 1995. It was designed as a prospective survey with at least 3 year follow-up. Included in the study were: patients who had isolated closed traction injury with complete palsy and total root avulsions of the brachial plexus; those with no underlying disease that might have in¯uenced recovery of the repaired nerve; patients who were healthy and had no previous surgery around the shoulder; and patients who were able to enter the study within 1 month after the injury. Excluded were: non-compliant and non- cooperative patients; patients who had associated injury in the ipsilateral arm, forearm and hand; patients who were regular smokers and alcohol consumers (as delayed recovery of both motor and sensory function has been found in such patients who underwent neurotization for the treatment of brachial injuries and most of them had poor compliance); and patients who could not be followed up regularly. The diagnosis was con®rmed by electrodiagnosis and cervical myelography. All the patients were prepared for surgery as soon as possible and all underwent operation within 2 months of the ®rst visit or within 3 months of the injury. Surgical procedure The functions of the ipsilateral trapezius muscle, intercostal muscles and diaphragm were examined physically and radiographically before the operation. All muscles had to be normal before the patient could take part in the study. Pulmonary function tests were also carried out in every patient and all were within normal limits. The operation was done under general anaesthesia without the use of a muscle relaxant to facilitate donor nerve identi®cation and localization. The brachial plexus was explored via a ``Z'' incision starting from the upper part of the neck along the posterior border of the sternomastoid muscle, along the clavicle and ending at the deltopectoral groove. Dissec- tion identi®ed all nerve roots, trunks, divisions, cords and primary branches of the plexus. A nerve stimulator and locator was used to identify the functioning nerves during the operation. Patients were recruited to the study only if total avulsion of the roots from C5 to T1 roots was found. The ipsilateral phrenic nerve was then identi®ed at the anterior surface of the anterior scalene muscle. The nerve was dissected down to the retrosternal area to gain enough length for it to be directly joined to the suprascapular nerve. The ipsilateral spinal accessory 556 © 1999 The British Society for Surgery of the Hand. All rights reserved. Not for commercial use or unauthorized distribution. by on July 30, 2008 http://jhs.sagepub.com Downloaded from nerve was identi®ed along the anterior border of the trapezius muscle and cut distal to the second branch to avoid total denervation of the trapezius muscle. The musculocutaneous nerve was then cut at a level just after branching to supply the coracobrachialis muscle. A sural nerve graft from the ipsilateral leg, 9 to 10 cm in length, was used to connect the spinal accessory nerve to musculocutaneous nerve. The nerve graft was placed beneath the subcutaneous tissue over the clavicle. The repair of the nerves was performed under 16 to 20 x magni®cation with 9/0 or 10/0 nylon. The wound was sutured in layers and an interlocking sling was used to partially immobilize the operated shoulder for 3 weeks. The patient underwent the second operation, the contralateral C7 neurotization, at the end of the third week after the ®rst operation. The patient was put in a supine position under general anaesthesia without the use of muscle relaxant. Both upper limbs, neck, chest and both shoulders were prepared and draped. The contralateral C7 root was identi®ed via a transverse incision about 1 cm above the clavicle. The incision was started at the suprasternal region and ended at the distal third of the clavicle. The contralateral C7 root was dissected down to the level of division and motor function was tested by the nerve stimulator. Elbow and wrist extension had to be observed after the C7 was stimulated before neurotization was continued (Gu et al., 1998). The whole ipsilateral ulnar nerve was identi®ed and dissected from the wrist to the upper part of the arm. The superior ulnar collateral artery and veins at the upper arm were identi®ed and protected. The distal end of the ulnar nerve was cut at the wrist and passed under the skin of the upper chest to the exposed contralateral C7 root. The C7 root was blocked with 2 ml of 2% lidocaine to prevent chronic pain and to protect the corresponding neurons (Gu, 1994; Gu et al., 1998). The anterior part of the contralateral C7 root was cut to match the distal end of the ulnar nerve. Slow continuous bleeding from the cut surface of the distal end of the ulnar nerve was observed in every patient. However, to provide adequate blood supply to the long ulnar nerve graft, the ulnar artery and veins were harvested with the ulnar nerve in 50 patients randomly chosen by their hospital numbers. The distal end of the ulnar nerve was sutured to the proximal part of the contralateral C7 trunk and the ulnar vessels were anastomosed to the transverse cervical vessels with 9/0 nylon under 16 to 20 x magni®cation in these 50 patients. In the other 46 patients, the distal end of the ipsilateral ulnar nerve, which was based only on the superior ulnar collateral vessels, was sutured to the proximal part of the contralateral C7 trunk for neurotization without vascu- larization from the ulnar vessels (Gu et al., 1998). At the upper arm the ulnar nerve was cut at the level proximal to the superior ulnar collateral vessels. The median nerve at the corresponding level was also cut. The proximal end of the distal part of the ulnar nerve was then sutured to the proximal end of the distal part of the median nerve. The wounds were closed and the ipsilateral upper limb was partially immobilized in shoulder adduction and elbow ¯exion for 6 weeks. Full range of shoulder abduction was avoided for 12 weeks. No electrical stimulation was used postoperatively. Electrophysiological monitoring of reinnervation of the suprascapular, biceps and pronator teres muscles was done every 3 months. Synchronized exercise with the muscles of the donor nerves was started when the neurotized muscles showed signs of reinnervation. Measurement Perioperative conditions, complications of surgery, neurological signs of the donor site, pain, and lung function were measured, recorded and analysed. A visual analogue scale (VAS) was used to de®ne pain intensity as follows: 0±3 mild pain; 3±5 moderate pain; and over 5 severe pain. Motor power and sensory function of the injured upper limb were assessed and graded (Sunderland, 1991). The patients were followed up every month after surgery. In comparing the results after vascularized and nonvascularized ulnar nerve grafting, and the eects of age on the outcome, discrete data were analysed by the w2 test and the continuous data were analysed by Student's t-test. RESULTS There were 96 male patients in our study with ages ranging from 13 to 48 years. There were no serious complications during and after the surgery. Only three patients had local wound infections and all responded well to local management and systemic antibiotics for a few weeks. Eleven patients needed blood transfusion. No patient had chronic pain syndrome in the upper limbs either on the injured or C7 root donor sides at the 3 year follow-up. There was also no signi®cant Table 1ÐOverall motor recovery of patients at the 3 year follow-up after contralateral C7 neurotization Functions No. of patients (%) (n=96) Active shoulder abduction 4608 81 (85%) 4608 15 (15%) Active elbow ¯exion M 3 or better 85 (88%) M 0 to M 2 11 (12%) Forearm pronation M 3 or better 32 (33%) M 0 to M 2 64 (67%) Wrist ¯exion M 3 or better 28 (29%) M 0 to M 2 68 (71%) Finger ¯exion M 3 or better 20 (21%) M 0 to M 2 76 (79%) CONTRALATERAL C7 NEUROTIZATION 557 © 1999 The British Society for Surgery of the Hand. All rights reserved. Not for commercial use or unauthorized distribution. by on July 30, 2008 http://jhs.sagepub.com Downloaded from neurological de®cit on the contralateral C7 distribution at the 3 year follow-up. Eleven patients had mild weakness of wrist extension and numbness in the ®rst web space for 6 months and another four patients complained of mild weakness of wrist ¯exion for 4 months after the operation. All regained normal activity in the contralateral C7 distribution within 1 year of the operation. Abnormal lung function tests were observed in 60 patients who had a decrease in vital capacity and FEV1/ FEV ratio for 3 to 6 months after the operation. Almost all patients had normal lung function at the 3 year follow- up except 2 patients who were 13 and 14 years old. Motor function at the shoulder and elbow was signi®cantly improved in 85 and 88%, respectively, of all patients who had the combination of phrenic and spinal accessory nerve neurotization (Table 1). How- ever, motor function at the forearm, wrist and hand was rather poor after contralateral C7 neurotization of the median nerve. Only 20 and 30%, respectively, of the patients had signi®cant improvement of forearm and hand function (Table 1). Signi®cant sensory recovery improvement was observed in most patients (Table 2). Using a vascular- ized ulnar nerve graft by anastomosing the harvested ulnar vessels to the transverse cervical vessels had no signi®cant eect on motor and sensory recovery after Table 2ÐOverall recovery of sensory function at the palm after contra- lateral C7 neurotization at the 3 year follow-up Tests No. of patients (%) (n=96) Pinprick P 3 or better 80 (83%) P 0 to P 2 16 (17%) Moving light touch T 3 or better 72 (75%) T 0 to T 2 24 (25%) Temperature sense T8 3 or better 66 (69%) T8 0 to T8 2 30 (31%) Table 3ÐA comparison of motor and sensory recovery of forearm and hand in patients who received contralateral C7 neurotization to median nerve using ulnar nerve graft with and without revascularization by transverse cervical vessels at the 3 year follow-up Contralateral C7 neurotization using ulnar nerve graft P-value With revascularization Without revascularization (n50) (n46) Age (years) Mean 26.4 27.0 NS Range 13 to 45 15 to 48 Body weight (kg) Mean 45.4 46.3 NS Range 20 to 80 22 to 76 Height (cm) Mean 140.4 144 NS Range 130 to 180 130 to 181 Length of ulnar nerve graft (cm) Mean 29.9 30.1 NS Range 18 to 42 19 to 44 Blood transfusion Yes 6 5 NS No 44 41 Complications Yes 2 1 NS No 48 45 Forearm pronation M 3 or better 18 14 NS M 0 to M 2 32 32 Wrist ¯exion M 3 or better 15 13 NS M 0 to M 2 35 33 Finger ¯exion M 3 or better 11 9 NS M 0 to M 2 39 37 Pinprick at palm P 3 or better 44 36 NS P 0 to P 2 6 10 Moving light touch at palm T 3 or better 37 35 NS T 0 to T 2 13 11 Temperature sense at palm T8 3 or better 36 30 NS T8 0 to T8 2 14 16 558 THE JOURNAL OF HAND SURGERY VOL. 24B No. 5 OCTOBER 1999 © 1999 The British Society for Surgery of the Hand. All rights reserved. Not for commercial use or unauthorized distribution. by on July 30, 2008 http://jhs.sagepub.com Downloaded from contralateral C7 to median nerve neurotization (Table 3). The age of the patient was the most important factor determining the motor outcome of contralateral C7 to median nerve neurotization (Table 4). Signi®cant motor recovery of forearm and hand function was found in about 60% of patients younger than 18 years, while only about 10 to 25% of the patients who were older than 18 years had acceptable motor improvement (Table 4). DISCUSSION Our results of motor function reconstruction at the shoulder and elbow were similar to previous reports which showed 80 to 90% acceptable to good motor improvement (Allieu and Cenac, 1988; Chuang et al., 1995; Nagano et al., 1992; Narakas and Hentz, 1988; Songcharoen et al., 1996). Shoulder abduction was slightly limited because only neurotization of the suprascapular nerve by the phrenic nerve was done. Good shoulder abduction has been reported when both suprascapular and axillary nerves were neurotized (Chuang et al., 1995). However, when there was total root avulsion as in our patients, very few donor nerves were available. Furthermore, elbow ¯exion had to be restored and the spinal accessory nerve was used for reconstruction of this function. Neurotization of the axillary nerve was not therefore done in this study. The ipsilateral intercostal nerves were preserved to prevent deterioration of lung function, because the ipsilateral phrenic nerve had already been used. Our results of contralateral C7 root to median nerve neurotization were rather poor in terms of motor function. Only 20 to 30% of all patients regained signi®cant function. The ulnar nerve graft might have been too long. This may have been the reason that less motor power of forearm and hand muscles was observed than we had expected. The average length of the ulnar nerve combining with the median nerve, which the axons of the contralateral C7 trunk had to grow and pass to the forearm muscles, was 43.5 cm in adults and 32.7 cm in children and adolescents. Many of the neuromuscular junctions in the denervated forearm muscles might have degenerated before reinnervation occurred even though the operation was carried out within 3 months of the injury. These results were quite dierent from previous reports which showed satisfactory motor improvement in about 60% of patients (Chen and Gu, 1994; Gu et al., 1998). To improve power of ®nger ¯exion, a free gracilis transfer to the long ®nger and thumb ¯exors, innervated by median nerve neurotized by the contralateral C7, is now under study. Our early results are encouraging but more patients in dierent age groups are still needed for ®nal analysis. We found no signi®cant dierence in terms of motor recovery in the forearm and hand using a vascularized ulnar nerve graft, compared with an ulnar nerve graft which involved only the superior ulnar collateral vessels Table 4ÐA comparison of motor and sensory recovery of forearm and hand in patients who were older than 18 years and those who were 18 years and younger at the 3 year follow-up Age P-value 418 years old 418 years old (n22) (n74) Blood transfusion Yes 9 2 No 13 72 P50.05 Complications Yes 1 2 NS No 21 72 Forearm pronation M 3 or better 14 18* M 0 to M 2 8 56 P50.05 Wrist ¯exion M 3 or better 20 8* M 0 to M 2 2 66 P50.05 Finger ¯exion M 3 or better 14 6* M 0 to M 2 8 68 P50.05 Pinprick at palm P 3 or better 20 60 P 0 to P 2 2 14 P50.05 Moving light touch at palm T 3 or better 22 50 No data T 0 to T 2 ± 24 Temperature sense at palm T 3 or better 17 49 T 0 to T 2 5 25 P50.05 * No M 4 or better was observed CONTRALATERAL C7 NEUROTIZATION 559 © 1999 The British Society for Surgery of the Hand. All rights reserved. Not for commercial use or unauthorized distribution. by on July 30, 2008 http://jhs.sagepub.com Downloaded from (Table 3). These ®ndings dier from those reported by Gu et al. (1998). Only the age of our patients, which also determined the length of the ulnar nerve graft, signi®cantly in¯uenced motor recovery (Table 4). Gu et al. (1998) also reported better motor recovery in those patients who were younger than 40 years. Contralateral C7 to median nerve neurotization may be a useful procedure for total root avulsion in children. Sinsory recovery in the hand after contralateral C7 to median nerve neurotization was very promising in our patients. Speci®c sensory tests were used to de®ne the quality of sensation in this study (Sunderland, 1991). As well as motor recovery, recovery of sensory function is a very important factor in¯uencing the functional out- come of neurotization after brachial plexus injury. Intercostal nerve neurotization usually restores only sensation (Ogino and Naito, 1995). We found that sensory recovery in the hand after contralateral C7 root to median nerve neurotization is much better than after intercostal nerve neurotization to the same nerve. References Allieu Y, Cenac P (1988). Neurotization via the spinal accessory nerve in complete paralysis due to multiple avulsion injuries of the brachial plexus. Clinical Orthopaedics and Related Research, 237: 67±74. Chen L, Gu YD (1994). An experimental study of contralateral C7 root transfer with vascularized nerve grafting to treat brachial plexus root avulsion. Journal of Hand Surgery, 19B: 60±66. Chuang DC, Lee GW, Hashem F, Wei FC (1995). Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plastic and Reconstructive Surgery, 96: 122±128. Gu YD (1994). Distribution of the sensory endings of the C7 nerve root and its clinic signi®cance. Journal of Hand Surgery, 19B: 67±68. Gu YD, Chen DS, Zhang GM et al. (1998). Long term functional results of contralateral C7 transfer. Journal of Reconstructive Microsurgery, 14: 57±59. Gu YD, Shen LY (1994). Electrophysiological changes after severance of the C7 nerve root. Journal of Hand Surgery, 19B: 69±71. Nagano A, Ochiai N, Okinaga S (1992). Restoration of elbow ¯exion in root lesions of brachial plexus injuries. Journal of Hand Surgery, 17A: 815±821. Narakas AO, Hentz VR (1988). Neurotization in brachial plexus injuries. Indication and results. Clinical Orthopaedics and Related Research, 237: 43±56. Ogino T, Naito T (1995). Intercostal nerve crossing to restore elbow ¯exion and sensibility of the hand for root avulsion type of brachial plexus injury. Microsurgery, 16: 571±577. Songcharoen P, Mahaisavariya B, Chotigavanich C (1996). Spinal accessory neurotization for restoration of elbow ¯exion in avulsion injuries of the brachial plexus. Journal of Hand Surgery, 21A: 387±390. Sunderland S. Nerve injuries and their repair: a critical appraisal. Edinburgh, Churchill Livingstone, 1991: 281±332. Received: 16 February 1999 Accepted after revision: 24 May 1999 S. Waikakul MD, Department of Orthopaedic Surgery, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. E-mail: rawwk@mahidol.ac.th # 1999 The British society for Surgery of the Hand Article no. jhsb.1999.0264 560 THE JOURNAL OF HAND SURGERY VOL. 24B No. 5 OCTOBER 1999 © 1999 The British Society for Surgery of the Hand. All rights reserved. Not for commercial use or unauthorized distribution. by on July 30, 2008 http://jhs.sagepub.com Downloaded from