| Objective①Explore the feasibility of contralateral C7 (cC7) transfer to lower trunk via a subcutaneous tunnel across the anterior surface of chest and neck for total root avulsion of the brachial plexus;②explore the matching between cC7 nerve root and the repaired nerves,③compare nerve regeneration distance in our surgical method with in conventional cC7 transposition (vascularized ulnar nerve bridging the cC7 nerve root and median nerve).Methods Twelve adult cadaver specimens were used for this study. Bilateral supraclavicular transverse incisions were used to explore the upper trunk, middle trunk and lower trunk of the brachial plexus. The length of cC7 nerve root was elongated by isolating and cutting its anterior and posterior division at division-to-cord level, then dissecting it proximally close to the intervertebral foramen. In bilateral infraclavicular longitudinal incisions, we isolated the medial cord proximally to C8 and T1 nerve root in supraclavicular area and distally to the inferior margin of the pectoralis major, severed the posterior division of lower trunk, the median nerve lateral head, medial anterior thoracic nerve, C8 and T1 nerve root close to the intervertebral foramen, then pulled lower trunk from supraclavicular fossa to infraclavicular area.①In the position of the affected shoulder anterior flexion 10°, adduction 30°and elbow flexion 90°,measure the distance between the cC7 nerve root and the C8 and T1 nerve roots via the subcutaneous tunnel on the anterior surface of chest and neck;②measure the distances from the medial epicondyle of humerus to C8-T1 nerve roots and cC7 nerve root;③measure the diameter, the total number of nerve fibers and nerve bundle area of the following nerves:C8,T1,C7,the anterior division of C7,the posterior division of C7,lower trunk, ulnar nerve, median nerve, the anterior branch of axillary nerve and the medial antebrachial cutaneous nerve.Results①In the position of the affected shoulder anterior flexion 10°, adduction 30°and elbow flexion 90°, the percentage of a direct anastomosis between the cC7 nerve root and the C8 and T1 nerve roots via the subcutaneous tunnel on the anterior surface of chest and neck was 93.7%.There was 4.85±2.13cm extra nerve at the nerve anastomotic site of the direct repaired specimens. In the specimens without direct suture, only short bridging by 2.38±1.87cm nerve grafts was necessary. The percentage of a direct suture between the cC7 nerve root and the lower trunk was 70.83% and an average of 3.34±1.46cm extra nerve at the nerve anastomotic site of the specimens with the cC7 directly to lower trunk. In the specimens that lower trunk was not repaired by the cC7 directly, a short bridging by 2.56±2.15cm nerve grafts was necessary.②Compared to the average fibers numbers, the diameter and nerve bundle area of ulnar nerve, those of the C7, the anterior division of C7 and the median nerve were larger, but those of the posterior division of C7 were roughly equal. The the average fibers numbers, the diameter and nerve bundle area of C8 and Tl nerve roots were larger than those of the anterior and posterior divisions of the C7.③The distances from the medial epicondyle of humerus to C8-T1 nerve roots and cC7 nerve root were 44.8±4.1cm and 37.1±3.3cm, respectively.Conclusions①The method that cC7 transferred to lower trunk via the subcuta-neous tunnel of chest and neck is feasible.②In terms of the number of nerve fibers and nerve thickness, compared to traditional surgical method, our method that the cC7 nerve root repaired lower turnk made the C7 fibers play a more effective role.③Our method greatly reduced the distance (at least 8cm) needed for nerve regeneration than the conventional method.Objective①Exploring the efficacy of the cC7 transfer to lower trunk for total root avulsion of the brachial plexus.②Comparing the functional recovery of injured limbs after treatment in our surgical method with in conventional cC7 transposition.Methods 40 female SD rats were individed into A, B, C and D group randomly. In group A (lower trunk group), the cC7 root transfer to lower trunk directly; In group B (conventional group), the cC7 root transfer to median nerve via vascularize ulnar nerve bridging the cC7 nerve root and median nerve; In group C (normal group), normal control group; In group D(without repairing group), the nerve of total root avulsion of the brachial plexus without being repaired. Twenty-four weeks after the operation, electrophsiologyical examination, neuromophometry, muscle fibers sectional area, the wet muscle weight and motor endplate detection were carried out to evaluate the outcome of each group.Results①The myelinated fiber counts and the nerve fiber diameter:in ulnar nerve, there were no difference between group A and group C (P>0.05); In median nerve, Group A (2017±956) was significantly more than group B (3535±329) and group C(4062±1395), but there were no difference between group B and group C; In the medial antebrachial cutaneous nerve, Group A(228±86) was significantly less than group C (809±318).②LAT and AMP of CMAP:in flexor carpi ulnaris (FCU), group A (16.677±4.408mA and 2.418±0.206ms) were actually slightly less than group C (16.822±4.156mA and 2.009±0.473ms)(P<0.05);In flexor digitorum superficialis (FDS),group A (14.11±2.926mA and 2.57±0.24 ms) were poor than group B (36.1±16.06mA and 1.76±0.21 ms) and group C (15.6±3.58mA and 2.11±0.48 ms), but there was no significant difference between group B and group C.③Wet muscle weight and muscle fibers sectional area:in FCU, group A were better than group B (0.05874±0.0061g and 546.02±45.45μm2) and group D (0.03±0.002g and 434.24±32.27μm2), but were worse than group C (0.1574±0.0106g and 731.49±41.61μm2); In FDS, group A (0.05904±0.0077g and 550.37±82.43μm2) were better than group D (0.0488±0.003g and 399.71±65.17μm2), but were worse than group B (0.0916±0. 02167g and 421.01±89.67μm2) and group C (0.1288±0.0174g and 801.59±106.72μm2), at the same times, group B were worse than group C.Conclusions①The method that cC7 transferred to lower trunk is feasible in terms of the recovery of electrophsiology, neuromophometry, muscle fibers sectional area and the wet muscle weight.②Compared to traditional surgical method, the recovery of flexors innervated by median nerve were worse in our method, but the recovery of flexors innervated by median and ulnar nerves were better in our method.Objective Explore the changes of the quantity and quality of the nerve fibers from median and ulnar nerves after cutting the branches of lower trunk which was repaired by the cC7.Methods 40 female SD rats were divided into A, B, C and D groups randomly. In group A, the cC7 root transfer to lower trunk directly, and severed the posterior division of lower trunk, the median nerve lateral head, medial anterior thoracic nerve and the medial antebrachial cutaneous nerve at the beginning of them; In group B, the cC7 root transfer to lower trunk directly, and severed the posterior division of lower trunk, the median nerve lateral head, medial anterior thoracic nerve and the medial antebrachial cutaneous nerve at the point which was 1cm away from the beginning of above branches; In group C, the cC7 root transfer to lower trunk directly, and severed the posterior division of lower trunk at the beginning of it; In group D, normal control group. Twenty-four weeks after the operation, count myelinated fiber, nerve fiber density, the percentage of the number of nerve fiber from branch accounting for that from lower trunk, nerve fiber diameter, the percentage of nerve fibers with different diameters and N Ratio were carried out to evaluate the outcome of each group.Results Myelinated fiber count, nerve fiber density, the percentage of the number of nerve fiber from branch accounting for that from lower trunk, nerve fiber diameter, the percentage of nerve fibers with different diameters and N Ratio:in ulnar and median nerve, there were no difference between group A, group B and group C (P>0.05); In medial anterior thoracic nerve and the medial antebrachial cutaneous nerve, there were no difference between group B and group C (P>0.05). Myelinated fiber count, nerve fiber density and the percentage of the number of nerve fiber from branch accounting for that from lower trunk of Group C was significantly less than group D in median nerve, medial anterior thoracic nerve and the medial antebrachial cutaneous nerve. In lower trunk, the myelinated fiber count, nerve fiber density, nerve fiber diameter and N Ratio of Group C was significantly less than group D.Conclusions①After the posterior division of lower trunk, the median nerve lateral head, medial anterior thoracic nerve and the medial antebrachial cutaneous nerve,from lower trunk which was repaired by the cC7, were severed at the beginning and at the point which was 1cm away from the beginning of above branches, the changes of the quantity and quality of the nerve fibers from median, ulnar nerves, residue segments of medial anterior thoracic nerve and the medial antebrachial cutaneous nerve were not significant.②Myelinated fiber count, nerve fiber density and the percentage of the number of nerve fiber from branch accounting for that from lower trunk, in lower trunk and its branches, were less than normal ones; But the nerve fiber diameter and N Ratio were similar to the normal ones.Objective①Explore the efficacy of the branch of lower trunk, which was repaired by the cC7, transferred to injured nerves.②Explore the functional changes of the flexors innervated by ulnar nerve and median nerve after the branches of lower trunk were transferred to injured nerves.Methods 40 female SD rats were individed into A, B, C and D group randomly. In group A (lower trunk group),the cC7 root transfer to lower trunk directly; In group B (axillary nerve group), the medial antebrachial cutaneous nerve transferred to the anterior branch of axillary nerve;In group C (normal group), normal control group;In group D(without repairing group), the nerve of total root avulsion of the brachial plexus without being repaired. Twenty-four weeks after the operation, electrophsiolo-gyical examination, neuromophometry, muscle fibers sectional area, the wet muscle weight and motor endplate detection were used to evaluate the outcome of each group.Results①The myelinated fiber counts:in the medial antebrachial cutaneous nerve and axillary nerve, Group B (222±71 and 1095±76) was significantly less than group C (809±318 and 2454±800).②AMP and LAT of CMAP:in deltoid, group B (10.759±1.431mA and 3.190±0.408ms) were actually slightly less than group C(13.191±2.767mA and 2.535±0.219ms) (P< 0.05).③Wet muscle weight and muscle fibers sectional area:in deltoid, group B (0.221±0.054g and 1010.69±115.56μm2) were worse than group C (0.249±0.031g and 943.87±159.79μm2).④AMP and LAT of CMAP:in FCU and FDS, there were no significant difference between group A (16.677±4.408mA and 2.418±0.206ms;12.745±2.080mA and 2.57±0.24ms) and group B (14.25±3.40mA and 2.634±0.200ms; 12.503±2.223mA and 2.83±0.41ms), but group A and group B were actually slightly less than group C (16.822±4.156mA and 2.009±0.473ms;17.100±3.853mA and 2.11±0.48ms) (P<0.05).⑤Wet muscle weight and muscle fibers sectional area:in FCU and FDS, there were no significant difference between group A (0.129±0.007g and 546.02±45.45μm2; 0.0885±0.004g and 550.37±82.43μm2) and group B(0.128±0.026g and 640.49±75.42μm2; 0.0880±0.017g and 714.33±117.03μm2), but group A and group B were actually slightly worse than group C(0.161±0.017g and 731.49±41.61μm2; 0.1288±0.0174g and 801.59±106.72μm2) and better than group D(0.03±0.002g and 434.24±32.27μm2;0.0488±0.003g and 399.71±65.17μm2) (P< 0.05)Conclusions①After the lower trunk was repaired by the cC7 nerve root, it was effective to transfer the branch of lower trunk to injured nerve, which did not weaken the functional recovery of flexor innervated by ulnar nerve and median nerve.Objective We sought to investigate an innovative and efficacious procedure for restoring wrist flexion, finger flexion and hand sensation by passing the cC7 through a subcutaneous tunnel across the anterior surface of chest and neck.Methods Four patients (3 men,1 woman) with total brachial plexus avulsion were treated from November 2005 to July 2007, their ages ranging from 18 to 36 (average, 26 years). The operative delay was from 23 days to 5 months (mean,2 months). The cC7 nerve root was employed to repair the injured lower trunk or the C8-T1 spinal nerves via the subcutaneous tunnel across the anterior surface of chest and neck. Direct neurorrhaphy was performed on the C8-T1 residual nerve roots in two patients. In the other two patients, a nerve graft of 4.5cm in length was employed to restore the function of the affected lower trunk.Results Postoperative electromyography at 26 and 38 months recorded compound muscle action potentials and motor unit potentials in the abductor digiti minimi and the flexor pollicis longus in all cases. On clinical examination digital flexion scored, three cases for M2 and one for M3; carpal flexion, three cases for M3 and one case for M4; hand sensation, two cases for S2 and the othrer two cases for S3.Conculsions Transfer of the cC7 to the lower trunk proved to be a safe and feasible procedure. Compared with the traditional transfer of the cC7 to the median nerve, it might help patients gain better restoration of wrist flexion, finger flexion and hand sensation.
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