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Intercostal to musculocutaneous nerve transfer in patients with complete traumatic brachial plexus injuries: case series

  • Original Article - Peripheral Nerves
  • Published:
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Abstract

Background

To recover biceps strength in patients with complete brachial plexus injuries, the intercostal nerve can be transferred to the musculocutaneous nerve. The surgical results are very controversial, and most of the studies with good outcomes and large samples were carried out in Asiatic countries. The objective of the study was to evaluate biceps strength after intercostal nerve transfer in patients undergoing this procedure in a Western country hospital.

Methods

We retrospectively analyzed 39 patients from 2011 to 2016 with traumatic brachial plexus injuries receiving intercostal to musculocutaneous nerve transfer in a rehabilitation hospital. The biceps strength was graded using the British Medical Research Council (BMRC) scale. The variables reported and analyzed were age, the time between trauma and surgery, surgeon experience, body mass index, nerve receptor (biceps motor branch or musculocutaneous nerve), and the number of intercostal nerves transferred. Statistical tests, with a significance level of 5%, were used.

Results

Biceps strength recovery was graded ≥M3 in 19 patients (48.8%) and M4 in 15 patients (38.5%). There was no statistical association between biceps strength and the variables. The most frequent complication was a pleural rupture.

Conclusions

Intercostal to musculocutaneous nerve transfer is a safe procedure. Still, biceps strength after surgery was ≥M3 in only 48.8% of the patients. Other donor nerve options should be considered, e.g., the phrenic or spinal accessory nerves.

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Abbreviations

BMRC:

British Medical Research Council Scale

BMI:

Body Mass Index

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Author information

Authors and Affiliations

  1. Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals, SMHS501, Brasilia, 70335-901, Brazil

    Marcio de Mendonça Cardoso & Ricardo Gepp

  2. Department of Neurological Surgery, Instituto Hospital de Base do Distrito Federal, Brasilia, Brazil

    Flávio Leão Lima

  3. Sarah Network of Rehabilitation Hospitals, Brasilia, Brazil

    Andreia Gushiken

Authors
  1. Marcio de Mendonça Cardoso
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  2. Ricardo Gepp
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  3. Flávio Leão Lima
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Corresponding author

Correspondence to Marcio de Mendonça Cardoso.

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Comments

This paper by Cardoso et al evaluates the outcomes of a cohort of patients with panplexal injury treated with intercostal nerve transfer for elbow flexion. The technique has been a work horse for more than 50 years and was popularized by Asian colleagues. This report provides an honest assessment of a standard nerve transfer performed in a leading center in South America.

Elbow flexion is the number one priority of brachial plexus reconstruction. It relies on 'nerve economics'. In complete injury, there are few resources, so they must be used wisely. Options include nerve grafting from any available nerve stumps; and/or nerve transfers: intercostals (ICN) and spinal accessory (SAN) being standard and phrenic and contralateral C7 nerves, more aggressive.

These authors use a standard protocol of ICNs and SAN transfers to obtain elbow flexion and shoulder stability. M3 or greater elbow flexion was achieved in 48.8% of their adult patients treated with ICN transfer. While this result may be lower than other well cited publications of nerve transfers using ICNs or other donors for elbow flexion (summarized in several recent meta-analyses), it is within range of what many other groups describe. Still, M3 function, while a reasonable result for the surgeon, is not particularly useful for the patient. In general, M4 elbow flexion should be the goal as it what patients need to perform most activities of daily living. M4 was achieved in 38.5% with this technique. In patients with panplexal injury, our group has been employing a novel technique of dual reinnervation using 4 ICNs: 2 to the native biceps and 2 to a free functioning muscle transfer for elbow flexion (and/or finger flexion) (1).

The paper highlights two major points (and opportunities) in the state of the art in the reconstruction of patients with complete brachial plexus injury:1. Given the limited available donors, how do we achieve the best outcome given the many variables (i.e., time from injury, age of patient, body mass index, and other injuries). What nerve transfer and what specific technique should we use to what recipient in which patient?2. What is the best outcome assessment? Clearly MRC is not scientifically rigid enough. Should we routinely be including other measures, such as dynamometry, endurance, and patient satisfaction scores?

Through international efforts as this, we can combine efforts to try to design the best mouse trap.

Robert J. Spinner,

Rochester, MN,USA

Reference:

1. Maldonado AA, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Free functioning gracilis muscle transfer versus intercostal nerve transfer to musculocutaneous nerve for restoration of elbow flexion after traumatic adult brachial plexus pan-plexus injury. Plast Reconstr Surg 2016;483e-8e.

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de Mendonça Cardoso, M., Gepp, R., Lima, F.L. et al. Intercostal to musculocutaneous nerve transfer in patients with complete traumatic brachial plexus injuries: case series. Acta Neurochir 162, 1907–1912 (2020). https://doi.org/10.1007/s00701-020-04433-3

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