| Part 1 Retrospective study of phrenic nerve transfers tomusculocutaneous nerve with nerve graft for brachial plexus avulsion Objective To analyze the length of nerve graft and Body Mass Index(BMI)’s influences on the effectiveness by taking a follow-up study of 17 brachial plexus injured patients who were received phrenic nerve transferred to musculocutaneous nerve with nerve graft in order to recover the elbow flexion.Methods A follow-up study was carried out on patients who had got the phrenic nerve transferred to musculocutaneous nerve with nerve graft from 2007 to 2010, the effectiveness and factors were observed. Patients were evaluated by British Medical Research Council (BMRC) grading system.17 patients were included,16 males and 1 female. The mean age was 32 years old(range 16 to 44) 。 The mean interval time between injury and surgery was 3 month (range 1 to 8 months).6 patients left side was injuried,11 with right side.16 patients were caused by traffic accident,1 for machine traction.Two patients were diagnosed with C5-C6/7 avulsion and 15 with C5-T1 avulsion.Results The mean follow-up period was 54 months(range 24 to 72). Superficial radial nerve was used as nerve graft for 14 patients comparing sural nerve for 3 patients. The mean length of nerve graft was 10.5cm (range 6 to 15cm). There were 12 patients whose body mass index (BMI) was below 25 and 5 patients with BMI between 25 and 30. Of the 17 patients,14 patients’biceps muscle achieved M3 level and above. The effective rate was 82.4%.3 patients’muscle recovery was MO-2 grade, accounting for 17.6%. Excellent and good elbow function score was 76.5%. The effectiveness was not different between groups with nerve graft shorter than 10cm and longer than 10cm. Type of injury and BMI didn’t affect the effectiveness of function recovery obviously.Conclusions Elbow flexion can be obtained by phrenic nerve transfer with graft effectively within 8 months delay. The length of nerve graft, type of injury and BMI didn’t make any influence on the function recovery of phrenic nerve transferred to musculocutaneous nerve for brachial plexus injured patients.Part 2 Retrospective study of different number of intercostal nerves transfer to neurotize the musculocutaneous nerve after traumatic brachial plexus avulsionObjective Traumatic brachial plexus lesions in adults are devastating injuries which lead to sever disability. Transfers of 2,3, or 4 intercostal nerves have been proposed for restoring elbow flexion. The purpose of this study is to compare the outcomes of different numbers of intercostal nerves transfer for elbow flexion and to determine whether age, body mass index (BMI), type of injury and preoperative delay influence outcome.Methods From 2004 to 2010,30 consecutive patients (2 female 30 male) had intercostal nerve transfer to musculocutaneous for brachial plexus injury. Elbow flexion strength was evaluated according to the British Medical Research Council (BMRC) grading system. The mean age was 33.7 years old(range 16 to 49)。 The mean interval time between injury and surgery was 5.1 month (range 1 to 12 months).15 patients were diagnosed with C5-C6/7 avulsion and 15 with C5-T1 avulsion.13 patients left side was injuried,17 with right side. 25 patients were caused by traffic accident,3 for fallen injury,1 for machine traction,1 for heavy thing hit.Results 23 of 30 patients recovered useful elbow flexion. In the 2ICN transfers group,6 of 9(66.7%) patients recovered useful elbow flexion, comparing 14 of 17(82.4%) patients who received 3ICN transfers. Of the 4 patients with 4ICN transfer,3 (75%) achieved useful recovery. The statistical analysis showed no significant difference among different number of ICNs transfer. There were 20 patients whose body mass index (BMI) was below 25 and 10 patients with BMI between 25 and 30. The postoperative follow-up period ranged from 24 to 104 months (mean,50.5 month). Excellent and good elbow function score was 73.3%.The preoperative delay (within one year), type of injury and BMI have no effect on the outcome of this procedure. Superior result was observed in people who was younger than 40 years old than those older than 40 years old.Conclusions 2ICN transfer is enough for useful recovery of elbow flexion. There were no difference among 2ICN,3ICN and 4ICN transfer to the musculocutaneous nerve respecting to the clinic efficiency. With two intercostal nerve transfer the rest of intercostal nerves could be used as donate for other nerve repair. The BMI of patients do not affect the outcome of recovery. Within 12 month delay, the ICN transfer to musculocutaneous nerve can obtain good results.Part 3 Clinical efficacy comparison of brachial plexus injury treatment:phrenic nerve transfer to musculocutaneous nerve with graft vs intercostal nerve transfer to musculocutaneous nerveObjective To investigate the final clinical efficacy by comparative analysis of phrenic nerve transfer to musculocutaneous nerve with graft and intercostal nerve transfer to musculocutaneous nerve.Methods Follow up the patients who were received phrenic nerve transfer to musculocutaneous nerve with graft or intercostal nerve transfer to musculocutaneous nerve for the treatment of brachial plexus injury from 2007 to 2010.17 patients were included in phrenic nerve group,16 males and 1 female; aged 16-44 years, mean 32 years. The interval time between injury and surgery was 1-8 months, an average of 3 months. Two cases were diagnosed with C5-C6 (7) root injuries, C5-T1 root injuries in 15 cases,6 cases of left and right 11 cases, traffic accident in 16 cases, the machine stretch injury in 1 case.27 patients were enrolled in intercostal nerve transfer group, including 25 males and 2 females, aged 16-49 years, mean 33.2 years, The interval time from 1 to 12 months, an average of 5.4 months, C5-C6 (7) in 13 cases, C5-T1 in 14 cases, the right side of injury 15 cases, left injury 12 cases, traffic accident in 22 cases, falls 3 cases, heavy thing hit 1 case, the machine traction in 1 case.Results Of 17 patients phrenic nerve transfer group, the biceps muscle achieved M3 level and above in 14 patients, the efficacy rate was 82.4%. Biceps muscle recovery was MO-2 grade in 3 cases, accounting for 17.6%. Of the 27 intercostal nerve transfer group patients, the biceps muscle achievedd M3 level and above in 20 cases, accounting for 74.1%, biceps muscle recovery MO-2 grade in 7 cases, contributing 25.9%. Difference between the two groups was not statistically significant (p= 0.716).Conclusions Phrenic nerve transfer to musculocutaneous nerve with graft and intercostal nerve transfer to musculocutaneous nerve were both effective surgical procedures to restore elbow flexion. The ultimate efficacy of the two procedures did not differ.Part 3 Clinical efficacy comparison of brachial plexus injury treatment:phrenic nerve transfer to musculocutaneous nerve with graft vs intercostal nerve transfer to musculocutaneous nerveObjective To investigate the final clinical efficacy by comparative analysis of phrenic nerve transfer to musculocutaneous nerve with graft and intercostal nerve transfer to musculocutaneous nerve.Methods Follow up the patients who were received phrenic nerve transfer to musculocutaneous nerve with graft or intercostal nerve transfer to musculocutaneous nerve for the treatment of brachial plexus injury from 2007 to 2010.17 patients were included in phrenic nerve group,16 males and 1 female; aged 16-44 years, mean 32 years. The interval time between injury and surgery was 1-8 months, an average of 3 months. Two cases were diagnosed with C5-C6 (7) root injuries, C5-T1 root injuries in 15 cases,6 cases of left and right 11 cases, traffic accident in 16 cases, the machine stretch injury in 1 case.27 patients were enrolled in intercostal nerve transfer group, including 25 males and 2 females, aged 16-49 years, mean 33.2 years, The interval time from 1 to 12 months, an average of 5.4 months, C5-C6 (7) in 13 cases, C5-T1 in 14 cases, the right side of injury 15 cases, left injury 12 cases, traffic accident in 22 cases, falls 3 cases, heavy thing hit 1 case, the machine traction in 1 case.Results Of 17 patients phrenic nerve transfer group, the biceps muscle achieved M3 level and above in 14 patients, the efficacy rate was 82.4%. Biceps muscle recovery was MO-2 grade in 3 cases, accounting for 17.6%. Of the 27 intercostal nerve transfer group patients, the biceps muscle achievedd M3 level and above in 20 cases, accounting for 74.1%, biceps muscle recovery MO-2 grade in 7 cases, contributing 25.9%. Difference between the two groups was not statistically significant (p= 0.716).Conclusions Phrenic nerve transfer to musculocutaneous nerve with graft and intercostal nerve transfer to musculocutaneous nerve were both effective surgical procedures to restore elbow flexion. The ultimate efficacy of the two procedures did not differ.Part 4 Experimental study on treatment of brachial plexus avulsion by phrenic nerve transfer and intercostal nerve transferObjective To imitate human brachial plexus injury by animal model. To compare the efficiency of treatment of brachial plexus injury by phrenic nerve transfer or intercostal nerves transfer to the musculocutaneous nerve.Methods 90 Sprague Dawley(SD) rats were randomized into 5 groups. The right upper limb was selected to create C5-C7 avulsion model and the left was preserved as the control side. Different operations were performed in different groups:phrenic transfer to anterior division of upper trunk (ADUT) (group A); phrenic nerve transfer to the musculocutaneous nerve with nerve graft(group B); two intercostal nerves transfer to the musculocutaneous nerve(group C); three intercostal nerves transfer to the musculocutaneous nerve(group D); four intercostal nerves transfer to the musculocutaneous nerve(group E). Functional outcomes were measured by the Terzis grooming test, electromyography, biceps muscle force measurements, muscle weight, the mean cross-sectional area of muscle fiber and axon counts at first, second, third month postoperative. The values of the control side parameters were expressed as a standard score. The relative standings of each group on each parameter were compared.Results Superior outcome was observed in the phrenic nerve transfer to anterior division of upper trunk group comparing to the phrenic nerve transfer to the musculocutaneous nerve with nerve graft group and two intercostal nerves transfer group(p<0.05) at first month postoperative. There were no significant differences between groups at second and third month postoperative except for the myelinated axon counts which indicated that the four intercostal nerves group was better comparing to the phrenic nerve transfer to the musculocutaneous nerve with nerve graft group and two intercostal nerves transfer group.Conclusions The phrenic nerve transfer to ADUT group recovered much earlier than other groups. There was no difference between phrenic transfer to ADUT group and phrenic to musculocutaneous nerve with graft group. The results between 2ICN,3ICN,4ICN transfer to musculocutaneous nerve groups were not significant. |
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