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Triceps Brachii Reinnervation in Primary Reconstruction of the Adult Brachial Plexus: Experience in 25 Cases

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Abstract

Background

Elbow flexion and shoulder abduction are the primary goals in brachial plexus surgery; however, reinnervation of the triceps is also an objective to be considered, as restoration of elbow extension improves the stabilization of the elbow and can provide a more powerful grasp. This study aims to demonstrate the author’s experience with restoration of elbow extension function in cases of brachial plexus surgery in adults.

Methods

Records of 25 patients sustaining traumatic brachial plexus injuries who were treated surgically with reinnervation of the triceps were reviewed. Nine techniques were employed, including posterior cord reconstruction and nerve transfers using donors such as the ipsilateral C7 root, phrenic nerve, medial pectoral nerve, intercostal nerves, the spinal accessory nerve, and a motor fascicle of the ulnar nerve. The targeted structure was the radial nerve or the branch to the long head of the triceps.

Findings

Twenty-one subjects (83%) obtained triceps reinnervation, and good results (M3 or better) were observed in 19 cases (76%). M4 grade was noted in 36% of the cases, M3 grade in 40%, M2 grade in 8%, M1 grade in 8%, and M0 grade in 8% of the patients. The best outcomes were observed in the cases presenting a C5 to C7 palsy and those in which the nerve to the triceps was chosen as the transfer target.

Conclusions

Reinnervation of the triceps can be achieved in most patients if adequate donor and recipient nerves are carefully selected based on an individual case-specific decision.

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Conflicts of interest

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Authors and Affiliations

  1. Unit of Neurosurgery, Hospital de Base do Distrito Federal, Post-Graduate Program in Medical Science, University of Brasília, SQN 208 Bloco F Apartamento 604, Asa Norte Brasília Distrito Federal, 70853-060, Brazil

    Leandro Pretto Flores

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  1. Leandro Pretto Flores
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Correspondence to Leandro Pretto Flores.

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Comment

Brachial plexus injuries due to some kinds of lesions have characteristics that need to be understood by neurosurgeons. For closed stretch injuries in cases of both neurapraxia and axonotmesis, reversible lesion functional regeneration usually occurs spontaneously, but the most serious problem is root avulsion lesions. In case of total avulsion the diagnostic as well as treatment options are difficult and in some aspects controversial. Decision-making depends on the preoperative neurological, radiological, and electrophysiological examinations. Horner signs and pseudomeningocele and electrophysiological study (electromyography and sensory nerve conduction examination) usually indicate the root avulsion. The treatment modality in such situations is limited and according to Kline (1) it is the definite diagnosis of root avulsion (false-positive signs of root avulsion 10%, false-negative 32%). According to Mehta (2), open surgery, however, gives us the chance to confirm the type of lesion. In case of partial avulsion, partial mending is possible by means of direct intraplexal repair or neurotization, if applicable. Elbow extension is one of the major restoration challenges, especially in cases of obstetric brachial plexus palsy, and early intraplexus reconstruction of the posterior cord can give excellent results. Terzis' article (3) provides the modern trends in brachial plexus closed injury treatment for C5–C7 spinal root palsy in order to obtain triceps function restoration. The conclusions and message from this article are somewhat limited by the heterogeneity of the different treatment options (9 different techniques were used for 25 patients). On the one hand, it shows that there are many possible options for treating patients and that each case should be considered and approached individually. On the other hand, we have learned from the article that the radial nerve branch of the long head of the triceps is more amenable to repair with nerve transfer methods than the radial nerve. Moreover, the article conveys the message that using the intercostal nerves as donors does not give good results. The paper is well documented, and I would like to point out the good methodology used by the author for patient selection (CT myelography as well as electrophysiology and the British MRC grading scale). Unfortunately, only a short comment is available about the microsurgical methods used in process of nerve repair. As we know, in some cases, progress in microsurgery of the peripheral nerves has made it possible for us to perform side-to-end anastomosis to avoid sacrificing the donor nerve. It is important when using the phrenic nerve as donor, especially in post-traumatic or congenital cases, when only one phrenic nerve functions satisfactorily. I also feel that the role of post-surgical rehabilitation should have been stressed as well in this undoubtedly interesting article.

References

1. Dubuisson AS, Kline DG (2002) Brachial plexus injury: A survey of 100 consecutive cases from a single service. Neurosurgery 51(3):673–681

2. Mehta VS, Banerji AK, Tripathi RP (1993) Surgical treatment of brachial plexus injuries. Br J Neurosurg 7:491–500

3. Terzis JK, Kokkalis ZT (2010) Restoration of elbow extension after primary reconstruction in obstetric brachial plexus palsy. J Pediatr Orthop 30:161–168

Andrzej Radek Lodz

Poland

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Flores, L.P. Triceps Brachii Reinnervation in Primary Reconstruction of the Adult Brachial Plexus: Experience in 25 Cases. Acta Neurochir 153, 1999–2007 (2011). https://doi.org/10.1007/s00701-011-1080-8

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  • DOI: https://doi.org/10.1007/s00701-011-1080-8

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