The aim of this paper is to report on our ample experience with the medial cord to musculocutaneous (MCMc) nerve transfer. The MCMc technique is a new type of neurotization which is able to reanimate the elbow flexion in multilevel avulsive injuries of the brachial plexus provided that at least the T1 root is intact. A series of 180 consecutive patients, divided into four classes according to the quality of hand function, is available for a long-term follow-up after brachial plexus surgery. The patients enrolled for the study have in common a brachial plexus palsy showing multiple cervical root avulsive injuries at two (C5-C6), three (C5-C6-C7) and four (C5-C6-C7-C8) levels. The reinnervation of the musculocutaneous nerve is obtained via an end-to-end transfer from two donor fascicles located in the medial cord. The selected fascicles are those directed principally to the flexor carpi radialis, ulnaris and, to a lesser degree, the flexor digitorum profundus. Under normal anatomic conditions, they are located in the medial cord, and their site corresponds to the inverted V-shaped bifurcation between the internal contribution of the median nerve and the ulnar nerve. The technique has no failure and no complications when the hand shows a normal wrist and finger flexion and a normal intrinsic function. In case of suboptimal conditions of the hand, the technique has proved technically more challenging, but still with 67 % satisfactory results. In the four-root avulsive injuries, however, this method shows its limitations and an alternative strategy should be preferred when possible. EMG analysis shows a reinnervation in both the biceps and the brachialis muscles, explaining the high quality of the observed results. Moreover, this technique theoretically offers the possibility of a “second attempt” at a more distal level in case of failure of the first surgery. This procedure is quick, safe, extremely effective and easily feasible by an experienced plexus surgeon. The ideal candidate is a patient harbouring a C5-C6 avulsive injury of the upper brachial plexus with a normally functioning hand.
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Flexor carpi ulnaris
Flexor carpi radialis
Common extensor of the fingers
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We are indebted to Mrs Mirella Wright for English support in the process of reviewing the manuscript.
Jörg Bahm, Aachen, Germany,
Nerve transfers are very selective microsurgical procedures on peripheral nerves, allowing specific sensitive or motor reinnervation of selected important functional targets. In a recent review, we also looked at the indications, the important technical steps and the possible anatomic variety of these procedures, applied to severe proximal nerve damages like in severe brachial plexus lesions (1). There are a lot of potential motor donors and targets, according to the extent of the lesion and the reconstructive priorities.
The team in Rovigo has a large and sound experience with severe brachial plexus lesions and comes up with an interesting rather proximal nerve donor, choosing selective motor fascicles out of the medial branch contributing to the median nerve, arising from the medial cord. Compared to Oberlin’s procedure, it is obvious that the origin of the donor fascicles out of the lower trunk allows a surgical indication even if the avulsion injury extends beyond the roots C5 and C6 to C7. This is a clear advantage.
On the recipient site, the authors show encouraging good results in functional recovery of the biceps-brachialis group, although the musculocutaneous nerve is targeted as a whole and not as selectively as compared to a single or double Oberlin type transfer. One even could imagine using the “motorized” initial sensitive branch of the musculocutaneous nerve for a specific motor nerve transfer more distally.
Ferraresi’s paper is thus not only interesting from a conceptual point of view, but also shows, based on a large patient group, how the results are affected by a growing extent of the lesion to the lower brachial plexus roots.
The donor morbidity is slow, as this is mandatory for all selective transfers harvesting functional capacity out of still working networks.
I want to express my congratulations to the authors for their creative, well-documented, and properly written work, adding a worthful procedure to the armament of functional nerve transfers in the upper limb.
(1) Bahm J, Elkazzi W, Schuind F.: les transferts nerveux. Rev Med Brux 2011 32: 54–7.
Electronic supplementary material
Below is the link to the electronic supplementary material.
MCMC transfer: surgical technique (MPG 35076 kb)
Normal hand function: excellent result on biceps endurance (MPG 9512 kb)
Normal hand function: excellent result on the biceps even without recruiting the wrist and finger flexors (MPG 10688 kb)
Good result on the biceps in spite of a wrist drop in C5-C6-C7 avulsive injury (MPG 28020 kb)
Good recovery of the biceps in spite of a suboptimal hand. The hand retained its strength (MPG 26984 kb)
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Ferraresi, S., Garozzo, D., Basso, E. et al. The medial cord to musculocutaneous (MCMc) nerve transfer: a new method to reanimate elbow flexion after C5-C6-C7-(C8) avulsive injuries of the brachial plexus—technique and results. Neurosurg Rev 37, 321–329 (2014). https://doi.org/10.1007/s10143-014-0522-1
- Brachial plexus injury
- Musculocutaneous nerve
- Nerve transfer
- Cervical root avulsion
- Brachial plexus repair
- Biceps muscle
- Brachial plexus