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Differences in strength fatigue when using different donors in traumatic brachial plexus injuries

  • Original Article - Peripheral Nerves
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Abstract

Background

The purpose of this study was to assess the results of elbow flexion strength fatigue, rather than the maximal power of strength, after brachial plexus re-innervation with phrenic and spinal accessory nerves. We designed a simple but specific test to study whether statistical differences were observed among those two donor nerves.

Method

We retrospectively reviewed patients with severe brachial plexus palsy for which either phrenic nerve (PN) or spinal accessory nerve (SAN) to musculocutaneous nerve (MCN) transfer was performed. A dynamometer was used to determine the maximal contraction strength. One and two kilograms circular weights were utilized to measure isometrically the duration of submaximal and near-maximal contraction time. Statistical analysis was performed between the two groups.

Results

Twenty-eight patients were included: 21 with a PN transfer while 7 with a SAN transfer for elbow flexion. The mean time from trauma to surgery was 7.1 months for spinal accessory nerve versus 5.2 for phrenic nerve, and the mean follow-up was 57.7 and 38.6 months, respectively. Statistical analysis showed a quicker fatigue for the PN, such that patients with the SAN transfer could hold weights of 1 kg and 2 kg for a mean of 91.0 and 61.6 s, respectively, while patients with transfer of the phrenic nerve could hold 1 kg and 2 kg weights for just a mean of 41.7 and 19.6 s, respectively. Both differences were statistically significant (at p = 0.006 and 0.011, respectively). Upon correlation analysis, endurances at 1 kg and 2 kg were strongly correlated, with r = 0.85 (p < 0.001).

Conclusions

Our results suggest that phrenic to musculocutaneous nerve transfer showed an increased muscular fatigue when compared with spinal accessory nerve to musculocutaneous transfer. Further studies designed to analyze this relation should be performed to increase our knowledge about strength endurance/fatigue and muscle re-innervation.

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Authors and Affiliations

  1. Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina

    Mariano Socolovsky, Gonzalo Bonilla, Ana Carolina Lovaglio & Gilda di Masi

Authors
  1. Mariano Socolovsky
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  2. Gonzalo Bonilla
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  3. Ana Carolina Lovaglio
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  4. Gilda di Masi
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Corresponding author

Correspondence to Mariano Socolovsky.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Comments

Over the past decade, Socolovsky et al. have tried to raise the bar for testing muscle strength. The vast majority of surgeons and neurologists use a grading classification, most commonly the MRC version. While a result of MRC 4 function for elbow flexion has been considered an excellent result, this group has recognized the fact that excellent is not good enough. Quite simply, there is a great variability within this commonly achieved group of patients (1), and there is more to an excellent result than just strength. This manuscript evaluates strength fatigue as well in patients undergoing nerve transfer for recovery of biceps function. This test may more accurately assess the “real-world” demands of elbow flexion, specifically the ability to sustain effort, rather than short bursts of maximal strength as is tested clinically by the MRC scale.

The introduction and implementation of this tool into our armentarium will enhance communication amongst international groups about specific outcomes and improve our understanding of mechanisms for recovery including rehabilitation and plasticity. Techniques such as what Socolovsky et al. describe can be used to study and compare outcomes for elbow flexion of different repairs and reconstructions (i.e., including the spinal accessory and phrenic nerves and other donors) as well as different targets (musculocutaneous vs biceps and/or brachialis muscles) at various time-points with long-term follow-up. In the end, we want to compare apples and apples rather than apples and oranges.

Courtney Pendleton,

Robert J. Spinner,

Rochester, MN

Reference:

1. MacAvoy MC, Green DP. (2007) Critical reappraisal of Medical Research Council muscle testing for elbow flexion. J Hand Surg 32:149-153.

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Socolovsky, M., Bonilla, G., Lovaglio, A.C. et al. Differences in strength fatigue when using different donors in traumatic brachial plexus injuries. Acta Neurochir 162, 1913–1919 (2020). https://doi.org/10.1007/s00701-020-04454-y

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  • DOI: https://doi.org/10.1007/s00701-020-04454-y

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