Advertisement

Neurosurgical Review

, Volume 37, Issue 2, pp 321–329 | Cite as

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

  • S. FerraresiEmail author
  • D. Garozzo
  • E. Basso
  • L. Maistrello
  • F. Lucchin
  • P. Di Pasquale
Original Article

Abstract

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.

Keywords

Brachial plexus injury Musculocutaneous nerve Nerve transfer Cervical root avulsion Brachial plexus repair Biceps muscle Brachial plexus 

Abbreviations

MC

Musculocutaneous

FCU

Flexor carpi ulnaris

FCR

Flexor carpi radialis

EDC

Common extensor of the fingers

Notes

Acknowledgments

We are indebted to Mrs Mirella Wright for English support in the process of reviewing the manuscript.

Supplementary material

Video 1

MCMC transfer: surgical technique (MPG 35076 kb)

Video 2

Normal hand function: excellent result on biceps endurance (MPG 9512 kb)

Video 3

Normal hand function: excellent result on the biceps even without recruiting the wrist and finger flexors (MPG 10688 kb)

Video 4

Good result on the biceps in spite of a wrist drop in C5-C6-C7 avulsive injury (MPG 28020 kb)

Video 5

Good recovery of the biceps in spite of a suboptimal hand. The hand retained its strength (MPG 26984 kb)

References

  1. 1.
    Allieu Y, Privat JM, Bonnel F (1982) Neurotization with the spinal nerve (nervus accessorius) in avulsions of roots of the brachial plexus. Neurochirurgie 28:115–120, FrePubMedGoogle Scholar
  2. 2.
    Allieu Y, Privat JM, Bonnel F (1987) Paralysis in root avulsion of the brachial plexus: neurotization by the spinal accessory nerve. In: Terzis JK (ed) Microreconstruction of nerve injuries. WB Saunders, Philadelphia, pp 415–423Google Scholar
  3. 3.
    Asfazadourian H, Tramond B, Dauge MC et al (1999) Morphometric study of the upper intercostal nerves: practical application for neurotizations in traumatic brachial plexus palsies. Chir Main 18:243–253PubMedGoogle Scholar
  4. 4.
    Aszmann OC, Rab M, Kamolz L et al (2000) The anatomy of the pectoral nerves and their significance in brachial plexus reconstruction. J Hand Surg [Am] 25:942–947CrossRefGoogle Scholar
  5. 5.
    Bertelli JA, Ghizoni MF (2004) Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg [Am] 29:131–139CrossRefGoogle Scholar
  6. 6.
    Blaauw G, Slooff AC (2003) Transfer of pectoral nerves to the musculocutaneous nerve in obstetric upper brachial plexus palsy. Neurosurgery 53:338–342PubMedCrossRefGoogle Scholar
  7. 7.
    Brandt KE, Mackinnon SE (1993) A technique for maximizing biceps recovery in brachial plexus reconstruction. J Hand Surg [Am] 18:726–733CrossRefGoogle Scholar
  8. 8.
    Brunelli G, Monini L (1984) Neurotization of avulsed roots of brachial plexus by means of anterior nerves of cervical plexus. Clin Plast Surg 11:149–152PubMedGoogle Scholar
  9. 9.
    Chuang DC (1995) Neurotization procedures for brachial plexus injuries. Hand Clin 11:633–645PubMedGoogle Scholar
  10. 10.
    Chuang DC, Lee GW, Hashem F et al (1995) Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 96:122–128PubMedCrossRefGoogle Scholar
  11. 11.
    El-Gammal TA, Fathi NA (2002) Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfers. J Reconstr Microsurg 18:7–15PubMedCrossRefGoogle Scholar
  12. 12.
    Ferraresi S, Garozzo D, Buffatti P (2004) Reinnervation of the biceps in C5-C7 brachial plexus avulsion injuries. Results after distal bypass surgery. Neurosurg Focus 16(5):E6PubMedGoogle Scholar
  13. 13.
    Ferraresi S, Garozzo D, Griffini C et al (1994) Brachial plexus injuries. Guidelines for management: our experience. Ital J Neurol Sci 15(6):273–284PubMedCrossRefGoogle Scholar
  14. 14.
    Ferraresi S, Garozzo D, Ravenni R et al (2002) Hemihypoglossal nerve transfer in brachial plexus repair: technique and results. Neurosurgery 50:332–335PubMedGoogle Scholar
  15. 15.
    Friedman AH, Nunley JA II, Goldner RD et al (1990) Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 72:59–64PubMedCrossRefGoogle Scholar
  16. 16.
    Giddins GE, Kakkar N, Alltree J et al (1995) The effect of unilateral intercostal nerve transfer upon lung function. J Hand Surg (Br) 20:675–676CrossRefGoogle Scholar
  17. 17.
    Gu YD, Cai PQ, Xu F et al (2003) Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus. Microsurgery 23:105–108PubMedCrossRefGoogle Scholar
  18. 18.
    Gutowski KA, Orenstein HH (2000) Restoration of elbow flexion after brachial plexus injury: the role of nerve and muscle transfers. Plast Reconstr Surg 106:1348–1359PubMedCrossRefGoogle Scholar
  19. 19.
    Hansasuta A, Tubbs RS, Grabb PA (2001) Surgical relationship of the medial pectoral nerve to the musculocutaneous nerve: a cadaveric study. Neurosurgery 48:203–207PubMedGoogle Scholar
  20. 20.
    Hattori Y, Doi K, Fuchigami Y et al (1997) Experimental study on donor nerves for brachial plexus injury: comparison between the spinal accessory nerve and the intercostal nerve. Plast Reconstr Surg 100:900–906PubMedCrossRefGoogle Scholar
  21. 21.
    Hattori Y, Doi K, Toh S et al (2001) Surgical approach to the spinal accessory nerve for brachial plexus reconstruction. J Hand Surg [Am] 26:1073–1076CrossRefGoogle Scholar
  22. 22.
    Hou Z, Xu Z (2002) Nerve transfer for treatment of brachial plexus injury: comparison study between the transfer of partial median and ulnar nerves and that of phrenic and spinal accessary nerves. Chin J Traumatol 5:263–266PubMedGoogle Scholar
  23. 23.
    Kawabata H, Shibata T, Matsui Y et al (2001) Use of intercostal nerves for neurotization of the musculocutaneous nerve in infants with birth-related brachial plexus palsy. J Neurosurg 94:386–391PubMedCrossRefGoogle Scholar
  24. 24.
    Kawai H, Kawabata H, Masada K et al (1988) Nerve repairs for traumatic brachial plexus palsy with root avulsion. Clin Orthop 237:75–86PubMedGoogle Scholar
  25. 25.
    Kierner AC, Zelenka I, Heller S et al (2000) Surgical anatomy of the spinal accessory nerve and the trapezius branches of the cervical plexus. Arch Surg 135:1428–1431PubMedCrossRefGoogle Scholar
  26. 26.
    Leechavengvongs S, Witoonchart K, Uerpairojkit C et al (1998) Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg [Am] 23:711–716CrossRefGoogle Scholar
  27. 27.
    Leechavengvongs S, Witoonchart K, Uerpairojkit C et al (2003) Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg [Am] 28:633–638CrossRefGoogle Scholar
  28. 28.
    Loy S, Bhatia A, Asfazadourian H et al (1997) Ulnar nerve fascicle transfer onto to the biceps muscle nerve in C5-C6 or C5- C6-C7 avulsions of the brachial plexus. Eighteen cases. Ann Chir Main Memb Super (Fre) 16:275–284CrossRefGoogle Scholar
  29. 29.
    Luedemann W, Hamm M, Blomer U et al (2002) Brachial plexus neurotization with donor phrenic nerves and its effect on pulmonary function. J Neurosurg 96:523–526PubMedCrossRefGoogle Scholar
  30. 30.
    Malessy MJ, Hoffmann CF, Thomeer RT (1999) Initial report on the limited value of hypoglossal nerve transfer to treat brachial plexus root avulsions. J Neurosurg 91:601–604PubMedCrossRefGoogle Scholar
  31. 31.
    Malessy MJ, Thomeer RT (1998) Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery. J Neurosurg 88:266–271PubMedCrossRefGoogle Scholar
  32. 32.
    Malessy MJ, van der Kamp W, Thomeer RT et al (1998) Cortical excitability of the biceps muscle after intercostal-to-musculocutaneous nerve transfer. Neurosurgery 42:787–795PubMedCrossRefGoogle Scholar
  33. 33.
    Mano Y, Nakamuro T, Tamura R et al (1995) Central motor reorganization after anastomosis of the musculocutaneous and intercostal nerves following cervical root avulsion. Ann Neurol 38:15–20PubMedCrossRefGoogle Scholar
  34. 34.
    Merrell GA, Barrie KA, Katz DL et al (2001) Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg [Am] 26:303–314CrossRefGoogle Scholar
  35. 35.
    Midha R (2006) Emerging techniques for nerve repair: nerve transfers and nerve guidance tubes. Clin Neurosurg 53:185–190, Lippincott Williams & WilkinsPubMedGoogle Scholar
  36. 36.
    Millesi H (1984) Brachial plexus injuries. Management and results. Clin Plast Surg 11:115–120PubMedGoogle Scholar
  37. 37.
    Minami M, Ishii S (1987) Satisfactory elbow flexion in complete (preganglionic) brachial plexus injuries: produced by suture of third and fourth intercostal nerves to musculocutaneous nerve. J Hand Surg [Am] 12:1114–1118CrossRefGoogle Scholar
  38. 38.
    Nagano A, Yamamoto S, Mikami Y (1995) Intercostal nerve transfer to restore upper extremity functions after brachial plexus injury. Ann Acad Med Singap 24(Suppl 4):42–45PubMedGoogle Scholar
  39. 39.
    Narakas AO (1984) Thoughts on neurotization or nerve transfers in irreparable nerve lesions. Clin Plast Surg 11:153–159PubMedGoogle Scholar
  40. 40.
    Oberlin C, Beal D, Leechavengvongs S et al (1994) Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg [Am] 19:232–237CrossRefGoogle Scholar
  41. 41.
    Ruch DS, Friedman A, Nunley JA (1995) The restoration of elbow flexion with intercostal nerve transfers. Clin Orthop 314:95–103PubMedGoogle Scholar
  42. 42.
    Samardzic M, Grujicic D, Antunovic V et al (1990) Reinnervation of avulsed brachial plexus using the spinal accessory nerve. Surg Neurol 33:7–11PubMedCrossRefGoogle Scholar
  43. 43.
    Samardzic M, Grujicic D, Rasulic L et al (2002) Transfer of the medial pectoral nerve: myth or reality? Neurosurgery 50:1277–1282PubMedGoogle Scholar
  44. 44.
    Samardzic M, Rasulic L, Grujicic D et al (2000) Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 46:93–103PubMedCrossRefGoogle Scholar
  45. 45.
    Samii A, Carvalho GA, Samii M (2003) Brachial plexus injury: factors affecting functional outcome in spinal accessory nerve transfer for the restoration of elbow flexion. J Neurosurg 98:307–312PubMedCrossRefGoogle Scholar
  46. 46.
    Samii M, Carvalho GA, Nikkhah G et al (1997) Surgical reconstruction of the musculocutaneous nerve in traumatic brachial plexus injuries. J Neurosurg 87:881–886PubMedCrossRefGoogle Scholar
  47. 47.
    Sedel L (1982) The results of surgical repair of brachial plexus injuries. J Bone Joint Surg Br 64:54–66PubMedGoogle Scholar
  48. 48.
    Songcharoen P (1995) Brachial plexus injury in Thailand: a report of 520 cases. Microsurgery 16:35–39PubMedCrossRefGoogle Scholar
  49. 49.
    Songcharoen P, Mahaisavariya B, Chotigavanich C (1996) Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus. J Hand Surg [Am] 21:387–390CrossRefGoogle Scholar
  50. 50.
    Sungpet A, Suphachatwong C, Kawinwonggowit V (2003) One-fascicle median nerve transfer to biceps muscle in C5 and C6 root avulsions of brachial plexus injury. Microsurgery 23:10–13PubMedCrossRefGoogle Scholar
  51. 51.
    Sungpet A, Suphachatwong C, Kawinwonggowit V (1998) Surgical anatomy of bicipital branch of musculocutaneous nerve. J Med Assoc Thai 81:532–535PubMedGoogle Scholar
  52. 52.
    Sungpet A, Suphachatwong C, Kawinwonggowit V et al (2000) Transfer of a single fascicle from the ulnar nerve to the biceps muscle after avulsions of upper roots of the brachial plexus. J Hand Surg (Br) 25:325–328CrossRefGoogle Scholar
  53. 53.
    Terzis JK, Papakonstantinou KC (2000) The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 106:1097–1124PubMedCrossRefGoogle Scholar
  54. 54.
    Terzis JK, Vekris MD, Soucacos PN (1999) Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg 104:1221–1240PubMedCrossRefGoogle Scholar
  55. 55.
    Tung TH, Mackinnon SE (2003) Brachial plexus injuries. Clin Plast Surg 30:269–287PubMedCrossRefGoogle Scholar
  56. 56.
    Tung TH, Novak CB, Mackinnon SE (2003) Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 98:313–318PubMedCrossRefGoogle Scholar
  57. 57.
    Viterbo F, Franciosi LF, Palhares A (1995) Nerve graftings and end-to-side neurorrhaphies connecting the phrenic nerve to the brachial plexus. Plast Reconstr Surg 96:494–495PubMedCrossRefGoogle Scholar
  58. 58.
    Waikakul S, Wongtragul S, Vanadurongwan V (1999) Restoration of elbow flexion in brachial plexus avulsion injury: comparing spinal accessory nerve transfer with intercostal nerve transfer. J Hand Surg [Am] 24:571–577CrossRefGoogle Scholar
  59. 59.
    Witoonchart K, Leechavengvongs S, Uerpairojkit C et al (2003) Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study. J Hand Surg [Am] 28:628–632CrossRefGoogle Scholar
  60. 60.
    Yamada S, Lonser RR, Iacono RP et al (1996) Bypass coaptation procedures for cervical nerve root avulsion. Neurosurgery 38:1145–1152PubMedGoogle Scholar
  61. 61.
    Yamada S, Peterson GW, Soloniuk DS et al (1991) Coaptation of the anterior rami of C-3 and C-4 to the upper trunk of the brachial plexus for cervical nerve root avulsion. J Neurosurg 74:171–177PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • S. Ferraresi
    • 1
    Email author
  • D. Garozzo
    • 1
  • E. Basso
    • 1
  • L. Maistrello
    • 1
  • F. Lucchin
    • 1
  • P. Di Pasquale
    • 1
  1. 1.Department of NeurosurgeryOspedale S. Maria della MisericordiaRovigoItaly

Personalised recommendations