Comparison between the anterior and posterior approach for transfer of the spinal accessory nerve to the suprascapular nerve in late traumatic brachial plexus injuries F. H. M Souza, S. N. Bernardino, H. C. Azevedo Filho, P. L. Gobbato, R. S. Martins, H. A. L. Martins & R P Silva-Néto Acta Neurochirurgica The European Journal of Neurosurgery ISSN 0001-6268 Acta Neurochir DOI 10.1007/s00701-014-2222-6
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Author's personal copy Acta Neurochir DOI 10.1007/s00701-014-2222-6
TECHNICAL NOTE - NEUROSURGICAL TECHNIQUES
Comparison between the anterior and posterior approach for transfer of the spinal accessory nerve to the suprascapular nerve in late traumatic brachial plexus injuries F. H. M Souza & S. N. Bernardino & H. C. Azevedo Filho & P. L. Gobbato & R. S. Martins & H. A. L. Martins & R P Silva-Néto
Received: 8 June 2014 / Accepted: 1 September 2014 # Springer-Verlag Wien 2014
Abstract Objective To evaluate the transfer of the spinal accessory nerve to the suprascapular nerve through the anterior or posterior approach in patients with late traumatic brachial plexus injuries. Methods This study includes patients with late brachial plexus injuries that underwent a spinal accessory-to-suprascapular nerve transfer. They were divided into two equal groups, A and B, in which the spinal accessory nerve was transferred to the suprascapular nerve, respectively, through the anterior or posterior approach. Narakas’s scale for assessment of the abduction of the arm and rotation of the shoulder was used. Results We studied 20 male patients with an age ranging from 18 to 42 years. In groups A and B, the mean age was 28±5.5 and 26±7.7 years, respectively. The time interval between injury and surgery was 9.5±1.6 and 10.9±2.5 months for groups A and B (p=0.12), respectively. In the 20 patients in groups A and B, we obtained a strength of shoulder abduction F. H. M. Souza : H. C. A. Filho Department of Neurosurgery of Hospital of the Restoration, Recife, Brazil S. N. Bernardino : H. A. L. Martins : R. P. Silva-Néto Department of Neuropsychiatry and Behavioral Sciences, Federal University of Pernambuco, Recife, Brazil P. L. Gobbato Department of Neurosurgery of Santa Casa of Porto Alegre, Porto Alegre, Brazil R. S. Martins Department of Neurosurgery, University of São Paulo, São Paulo, Brazil F. H. M. Souza (*) General Joaquim Ignácio Street, 830/1305, 1306, 50070-270 Recife, Brazil e-mail:
[email protected]
at 30°, respectively, M3 (in 4 and 5), M2 (in 4 and 2), M1 (in 2 and 2) and M0 (in zero and 1) (p=0.5). Regarding external rotation, group A showed M2 in only one patient and M0 in nine, while in group B, M3, in four; M2, in three; and M0, in three. In group B, the best results were observed in relation to the recovery of external rotation (p=0.008). Conclusions Better results in terms of external arm rotation were obtained when spinal accessory-to-suprascapular nerve transfer was performed using the posterior approach. Keywords Nerve transfer . Brachial plexus . Spinal accessory nerve . Suprascapular nerve
Introduction The shoulder stabilization and recovery of abduction are considered one of the priority objectives in brachial plexus surgery [2, 5]. The transfer of the accessory nerve to the suprascapular nerve (TAS) is one of the procedures used to achieve this goal and is usually used when there is no possibility of using the roots of the brachial plexus as donors for reconstruction grafts [14]. Usually this transfer is performed through the same access to the brachial plexus anterior approach [9]. However, despite the satisfactory results obtained with this technique, in some cases failure may occur. The occurrence of an injury to the suprascapular nerve in the scapular notch or nerve lesions not identified macroscopically justifies part of the unsatisfying results [7]. Comparatively, in some cases there is a lesion identified suprascapular nerve, which obviously prevents the realization of procedure [7]. In order to overcome these complications, some authors began to investigate the performance of TAS via posterior [3, 4, 8].
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The present study aims to compare the results between the anterior and posterior approaches to attainment of TAS in 20 patients.
Patients and methods Study design and patients This was a retrospective study with comparison of groups. The study population comprised 20 patients diagnosed with partial lesion of the brachial plexus after motorcycle accident. Subjects were randomly alternately assigned to the two groups of treatment. All patients were operated on in a referral hospital in neurosurgery in the city of Recife, in northeastern Brazil, from August 2008 to August 2010. Inclusion and exclusion criteria Patients were investigated in the usual way with MRI of the brachial plexus and electromyography. Considered eligible patients with brachial plexus lesions predominantly related to impairment of the upper roots (C5 and C6) and who had roots that irreparable damage preventing reconstruction with grafts with a minimum interval of 7 months between injury and surgery. The viability was defined by the root’s absence or presence of pseudomeningocele at MRI. Twenty males between 18 and 42 years old were included in this study and randomly divided into two groups. In group A, the accessory nerve was transferred to the suprascapular nerve by the anterior approach, and in group B, the accessory nerve was transferred to the suprascapular nerve through the posterior approach. Comparatively, in all cases the ulnar fascicle was transferred to the motor branch of the biceps [10, 13] and a branch of the radial nerve (triceps long head) to the axillary nerve [11].
access to the dorsal region. The location of the spinal accessory nerve (SA) was marked at a distance 40 % of the dorsal midline. It followed the acromion parallel to a line along the upper edge of the scapula (Fig. 1). The top angle of the scapula was marked and the location of the suprascapular fossa containing the suprascapular nerve (SS) was identified and marked at the midpoint between the superior angle of the scapula and the acromion along the upper border of the scapula. The incision was planned transversely to expose nerves [6]. A long incision (12 to 15 cm) was made parallel to scapular spine. Trapezius muscle was detached from the scapular spine. In some cases, we observed a thin fat layer between the two muscles. The trapezius muscle was carefully lifted, revealing neurovascular bundle on its anterior surface and accessory nerve was isolated. The contraction of the trapezius muscle was observed by electrical stimulation. The scapula edge upper was palpated with index finger. We identified the suprascapular notch and suprascapular transverse ligament (overlying the scapular notch) [4] (Fig. 2). The ligament was sectioned protecting the underlying suprascapular nerve. Lied nerve within tissue’s fatty. It was possible to identify a branch for supraspinatus muscle and also a branch for infraspinatus muscle. After performing coaptation, trapezius muscle was reattached to scapular spine. The subcutaneous tissue and skin were sutured without drain [8]. After conclusion of this step, we changed the patient position easily for supine position with the affected limb abducted to 90°. Thus, we had access to the arm medial aspect and, consequently, the neurovascular bundle, allowing transfer of ulnar nerve fascicle to the motor branch of the biceps [10, 13]. All cases were evaluated at regular intervals and followed for 18 months after surgery. Elbow flexion, shoulder abduction, external rotation, and extension strength were assessed
Surgical technique In group A, patients were positioned supine with the upper limb abducted to 90°. A transverse supraclavicular incision was made with goal of accomplishing the transfer of the accessory nerve to the suprascapular nerve. The plexus was not explored. The transverse cervical artery was followed by the trapezius muscle. After the entry of the artery in the trapezius muscle, the cranial nerve XI (spinal accessory) was located with the aid of a nerve stimulator, dissected distally, sectioned and transposed into suprascapular nerve, whose had identify and follow by omohyoid muscle. After their identification, sectioned close his origin [2]. Coaptation between two nerves was micro suture and biological glue. In group B, patients were placed in lateral decumbency with the injured limb supported and fixed to a clamp allowing
Fig. 1 A line along the upper edge of the scapula followed parallel to the acromion. The top angle of the scapula and the location of the suprascapular notch containing the suprascapular nerve (SS) were marked. SA spinal accessory nerve
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Results
Fig. 2 The trapezius muscle was lifted to the right, the supraspinatus muscle to the left, and the suprascapular ligament is evidenced
by Medical Research Council scale, with scores ranging from 0 (no evidence of contractility) to 5 (full range of motion against gravity with full resistance). The shoulder abduction and external rotation were classified based on the scale of Narakas [12, 15] with minor modifications. In assessing the shoulder abduction strength, we used M0, no evidence of contractility; M1, muscle contractions, but no active movement; M2, abduction less than 60°; M3, abduction more than 60° (for 10 s); M4, abduction to 60 ° against the resistance applied to elbow; and M5, abduction to 60 ° against resistance applied to forearm. In the assessment of external rotation, the patient standing with the shoulder fully internally rotated and the forearm placed transversely on the abdomen. We have classified as M0, no muscle contraction; M1, muscle contraction, but no active movement; M2, any active external rotation; M3, patient is able to maintain forearm in a horizontal position for 10 s; M4, movement active external rotation against resistance applied to proximal third of the forearm; and M5, active external rotation against resistance applied to the wrist.
Statistical analysis BioEstat version 5.0 software was used for statistical analysis. The quantitative variables were expressed as mean and standard deviation. Mann–Whitney test for comparison between groups was used, assuming a significance level of 0.05.
Ethical aspects This study was approved by the Ethics in Research Involving Human Subjects Committee, registry number CAAE 11046212.4.0000.5198 (Opinion: 299.451). All patients signed informed consent forms.
We studied 20 male patients with an age ranging from 18 to 42 years. In group A, the mean age was of 28±5.5 years and in group B, 26±7.7 years. The time interval between injury and surgery was, respectively, 9.5±1.6 months for group A, and 10.9±2.5 months for group B. There was no difference between the two groups regarding time between injury and surgery (Mann–Whitney test, p=0.12) (Table 1). In the ten patients in group A, we obtained shoulder stability (strength graduation in abduction at 30°) M3 in four patients; M2, in four patients; and M1, in two patients. In the ten patients in group B, we obtained abduction M3 in five patients; M2, in two patients; M1, in two patients and M0, in only one patient. The comparison between the two groups showed no statistical difference (Mann–Whitney test, p=0.5). Regarding external rotation, group A showed M2 in only one patient and M0 in nine, while in group B, M3, in four patients; M2, in three; and M0, in three. In group B, the best results were observed in relation to the recovery of external rotation (Mann–Whitney, p=0.008) (Table 2).
Table 1 Evaluation of groups A and B 24 months postoperatively
Group A Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Group B Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10
Age (years)
Time interval between injury and surgery (months)
Evaluation of the external rotation
Strength graduation in abducted (30°) shoulder
22 27 20 30 25 29 30 33 25 39
9 10 8 7 12 8 11 11 10 9
M2 M0 M0 M0 M0 M0 M0 M0 M0 M0
M2 M2 M3 M2 M3 M1 M2 M1 M3 M3
20 25
9 10
M3 M3
M3 M3
18 27 21 42 35 30 23 19
8 14 8 15 11 13 12 9
M3 M0 M3 M0 M2 M0 M2 M2
M3 M1 M3 M0 M2 M2 M1 M3
Author's personal copy Acta Neurochir Table 2 Shoulder abduction and external rotation of groups A and B 24 months postoperatively Narakas’s scale
Shoulder abduction Group A Group B External rotation Group A Group B
greater influence on late surgery, justifying the difference of results obtained by anterior or posterior approaches.
p value*
M0
M1
M2
M3
M4
M5
– 1
2 2
4 2
4 5
– –
– –
9 3
– –
1 3
– 4
– 0
– 0
Conclusions 0.5
0.008
The dorsal reinnervation of the suprascapular nerve is presented as an option to improve functional outcome in patients with late traumatic brachial plexus injuries.
Conflicts of interest There is no conflict of interest.
p value based on the Mann–Whitney test
Discussion
References
The direct transfer of the XI cranial nerve to the anterior suprascapular nerve is responsible for the recovery of external rotation in 70 % of patients [1]. In our series, as patients presented late for treatment, no surgery was performed before 6 months after injury and therefore the brachial plexus was not explored. The earliest was operated at 7 months (patient 4 in group A) from trauma and surgery later was 15 months of trauma (six patients in group B). Thus, in these cases, the nerve transfer is adopted as an initial procedure in detriment of primary surgery of the brachial plexus. Several factors to justify this approach late. All of the patients were evaluated for the first time between 4 and 6 months post-injury and the average time it took to perform imaging (MRI brachial plexus) and electromyography was 3– 6 months after the first evaluation. In group A, there was reinnervation of the supraspinatus nerve with shoulder stabilization in only one case, but there was no function in external rotation. As the brachial plexus injuries were due to motorcycle accidents in all of our cases, the absence of infraspinatus muscle reinnervation cannot be attributed to a trauma mechanism. Some conditions favored nerve transfers, such as accessory spinal-to-suprascapular nerve transfer in brachial plexus surgery including the possibility of direct inspection of the distal nerves receptors, shorter reinnervation due to proximity between nerve coaptation and effector, and work in a scar-free area. The use of the technique to transfer the dorsal accessory to suprascapular allowed evaluating some advantages [8]: (a) greater proximity to the muscle to be reinnervated; (b) leaving free nerve in an area where it could have been one second stretch injuries or direct injury; (c) exclusion of the articular branch reinnervation, preventing waste of axons; (d) preservation of former trapezius muscle without affecting the aesthetics and can be used as a second treatment option in the failure of reinnervation of deltoid (the insertion of the trapezius transfer to the humerus). These advantages may have a
1. Alnot JY, Rostoucher P, Oberlin C, Touam C (1998) C5-C6 and C5C6-C7 traumatic paralysis of the brachial plexus of the adult caused by supraclavicular lesions. Rev Chir Orthop Reparatrice Appar Mot 84:113–123 2. 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: 131–139 3. Bhandari PS, Sadhotra LP, Bhargava P, Bath AS, Mukherjee MK, Bhatti TS, Maurya S (2008) Multiple nerve transfers for the reanimation of shoulder and elbow functions in irreparable C5, C6 and upper truncal lesions of the brachial plexus. Indian J Neurotrauma 5: 95–104 4. Bhandari PS, Sadhotra LP, Bhargava P, Singh M, Mukherjee MK, Bhatoe HS (2010) Dorsal approach in spinal accessory to suprascapular nerve transfer in brachial plexus injuries: technique details. Indian J Neurotrauma\ 7:71–74 5. Birch R (2011) Repair of the roots of the spinal nerves in an avulsion lesion. The spinal accessory nerve. In: Surgical disorders of the peripheral nerves, 2nd edition. London: Springer-Verlag, pp 264–5 6. Colbert SH, Mackinnon S (2006) Posterior approach for double nerve transfer for restoration of shoulder function in upper brachial plexus palsy. Hand 1:71–77 7. Flores LP (2008) Suprascapular nerve release for treatment of shoulder and periscapular pain following intracranial spinal accessory nerve injury. J Neurosurg 109:962–966 8. Guan SB, Hou CL, Chen DS, Gu YD (2006) Restoration of shoulder abduction by transfer of the spinal accessory nerve to suprascapular nerve through dorsal approach: a clinical study. Chin Med J (Engl) 119:707–712 9. Kim DH, Murovic JA, Tiel RL, Kline DG (2004) Mechanisms of injury in operative brachial plexus lesions. Neurosurg Focus 16:E2 10. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Ketmalasiri W (1998) Nerve transfer to biceps muscle using part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg [Am] 23:711–716 11. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P (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: 633–638 12. Narakas AO (1995) Examen du patient et de la fonction des divers groupes musculaires du membre supérieur. In: Alnot JY, Narakas AO (eds) Les paralysies du plexus brachial, 2nd edn. Expansion Scientifique Française, Paris, pp 52–67
Author's personal copy Acta Neurochir 13. Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ (1994) Nerve transfer to biceps muscle using part of ulnar nerve for C5–C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg [Am] 19:232–237 14. Sulaiman OA, Kim DD, Burkett C, Kline DG (2009) Nerve transfer surgery for adult brachial plexus injury: a 10-year
experience at Louisiana State University. Neurosurgery 65(4 Suppl):A55–A62 15. Venkatramani H, Bhardwaj P, Reza-Faruquee S, Raja-Sabapathy S (2008) Functional outcome of nerve transfer for restoration of shoulder and elbow function in upper brachial plexus injury. J Brachial Plex Peripher Nerve Inj 3:15
