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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 1  |  Page : 178-183

Suprascapular nerve neurotization in obstetrical brachial plexus palsy using the spinal accessory nerve or the C5 root


1 Department of Neurosurgery, Faculty of Medicine, Menoufia University, Shibin Al Kawm, Egypt
2 Department of General Surgery, Plastic and Reconstructive Unit, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission03-Jun-2013
Date of Acceptance23-Sep-2013
Date of Web Publication20-May-2014

Correspondence Address:
Saeed E. Al-Emam
Department of Neurosurgery, Faculty of Medicine, Menoufia University, Yaseen Abdelghaffar Street, Shibin Al Kawm
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.132795

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  Abstract 

Objective
To evaluate the value of distal spinal accessory nerve (SAN) or 5th cervical (C5) root neurotization to the suprascapular nerve (SSN) in infants with obstetrical brachial plexus birth palsy.
Background
Surgical treatment of obstetrical brachial plexus birth palsy in infants includes neurolysis, nerve repair directly, or the use of interposition nerve graft and neurotization procedures. Repair of SSN is the key to restoration of shoulder joint function.
Materials and methods
Over a 3-year period, 30 infants with brachial plexus injuries were subjected to SSN repair, 18 infants by neurotization to the SAN and 12 infants by interposition nerve grafting to the C5 root as part of the primary surgical reconstruction. Operative and postoperative outcomes were evaluated with a minimum follow-up of 18 months.
Results
Neurotization of the SSN was performed by intraplexal neurotization using a nerve graft to C5 in 12 patients (40%) or extraplexal neurotization using SAN directly in 18 patients (60%). Nineteen infants were subjected to surgical reconstruction at less than 6 months of age and 11 were subjected to surgical reconstruction, age range 3 to 16 months, mean 5 months. At the latest follow-up, active shoulder movements were measured confirmed by review of videos. The outcome of nerve injury was assessed using the peripheral nerve injury unit scale. The results of neurotization and the use of an interpositional nerve graft were analyzed. SSN neurotization outcome by SAN showed 94.4% good outcome and 5.6% fair outcome, which were better than outcome by C5 root neurotization (66.7% good and 33.3% fair). Five patients developed a postoperative superficial wound infection.
Conclusion
Although both SAN and C5 root neurotization to the SSN nerve are reliable options for shoulder reinnervation in infants with obstetrical brachial plexus palsy, direct neurotization without an interpositional nerve graft yields better results.

Keywords: Brachial palsy, neurotization, suprascapular nerve


How to cite this article:
Al-Emam SE, Hewidi SA, Hanafey AM, Saleh EDG, Sheha AF. Suprascapular nerve neurotization in obstetrical brachial plexus palsy using the spinal accessory nerve or the C5 root. Menoufia Med J 2014;27:178-83

How to cite this URL:
Al-Emam SE, Hewidi SA, Hanafey AM, Saleh EDG, Sheha AF. Suprascapular nerve neurotization in obstetrical brachial plexus palsy using the spinal accessory nerve or the C5 root. Menoufia Med J [serial online] 2014 [cited 2020 Mar 30];27:178-83. Available from: http://www.mmj.eg.net/text.asp?2014/27/1/178/132795


  Introduction Top


Obstetrical brachial plexus palsy (OBPP) is unfortunately a rather common injury in newborn children. Its incidence varies between 0.15 and 3 per 1000 live births in various series and countries. Although spontaneous recovery is known, there is a large subset that does not recover and needs a primary or a secondary surgical intervention [1].

The nerves used for suprascapular nerve (SSN) neurotization include intraplexal and extraplexal motor donors. Intraplexal donors have a larger number of axons than extraplexal donors, and theoretically, this will increase the chance for successful nerve repair. However, it has been shown that, using the spinal accessory nerve (SAN) for SSN neurotization, the results obtained are similar to those after using intraplexal motor donors [2].

The first report of a nerve transfer in 1913 mentioned the use of the SAN as the donor nerve. In 1972, a description was made of the use of the distal part of the SAN in reinnervation of the upper limb, preserving fibers to the upper part of the trapezius [3].

The SAN has most commonly been transferred to the SSN to provide shoulder stability, abduction, and external rotation [4].

SAN neurotization has several advantages. It contains more motor fibers than motor fibers of three intercostal nerves. No respiratory function is disturbed, especially in patients who also have ipsilateral phrenic nerve paralysis from the same injury [5].

Additional weakness of the trapezius muscle does not essentially alter the total functional deficit of the shoulder after spinal root avulsion. However, the function of the trapezius muscle, especially that of the distal part, may be partially preserved because of independent innervation from the C3 spinal nerve (with an average of 740 motor fibers) and transection of the SAN distal to its branches [6].

The level of division of the SSN is selected on the basis of serial intraoperative frozen section histopathological analyses of the resected nerve segment. A tension-free direct end-to-end repair technique is performed outside the zone of injury using fibrin glue [7].


  Materials and methods Top


This prospective nonrandomized study included 30 infants with OBPP who underwent microsurgical management of the SSN by neurotization to the SAN or by grafting to the C5 root at Menoufia and Zagazig University Hospital from January 2010 to January 2013.

The aim of this study is to evaluate the value of distal SAN or 5th cervical (C5) root neurotization to the SSN in infants with obstetrical brachial plexus birth palsy.

Every patient was subjected to a detailed assessment of obstetric history including sex, mode of delivery and type of presentation, birth weight, the side involved, and associated injuries (as clavicular fractures, fracture humerus, head injuries, and diaphragmatic paralysis). Muscle strength was graded to evaluate the active range of motion, especially shoulder abduction, adduction, and external and internal rotations. After finishing the examination, the data obtained were interpreted and grading was performed using the hospital for sick children active movement scale. Investigations included an electrophysiological evaluation (preoperative EMG, nerve conduction studies) and a radiological evaluation (radiographss of the chest, clavicle, shoulder, and cervical computed topographic myelography).

The standard technique of nerve repair was used to repair injured roots of spinal nerves, trunks, cords, and peripheral nerves. Intraoperative decisions during procedures were guided by a nerve stimulator.

Operative technique

The patient was placed in a supine position. The head was turned to the noninvolved side. The chest was elevated with a roll pillow placed vertically between the two scapulae and the neck was hyperextended. The neck, the entire upper extremity involved, and both lower extremities were prepared. Long-acting muscle relaxants were not used to enable the use of nerve stimulation during the operation.

An incision was made two fingerbreadths over the clavicle posterior to and parallel to its upper border lateral to the sternocleidomastoid muscle. If this incision was not enough, it was extended through the deltopectoral groove to expose the lesion completely. The inferior belly of omohyoid muscle, transverse cervical vessels, and the phrenic nerve were structures that were useful during exploration. The phrenic nerve originates from the C3-5 roots and was located on the anterior scalene muscle. When this nerve was followed proximally, first C5 and then C6 were reached.

The SAN was identified in the posterior cervical at the medial border of the trapezius muscle and beneath the sternocleidomastoid muscle. The SAN was then confirmed by direct stimulation to distinguish it from cervical plexus branches. The SAN was traced distally till near the final bifurcation or trifurcation. The nerve was then reconfirmed by stimulation and divided as distal as possible and elevated superiorward to join the SSN.

The level of division of the SSN was selected on the basis of serial intraoperative section of the resected nerve segment neuroma till healthy nerve fascicle.

Surgery included a complete exploration of brachial plexus and SSN repair by microsurgical techniques using the operating microscope according to the intraoperative findings. Eighteen infants (60%) were managed by neurotization to SAN by direct microsutures or fibrin glue or both when the C5 root was avulsed or ruptured with an inaccessible proximal part, whereas 12 infants (40%) were managed by an interpositional sural graft to the C5 root when the C5 proximal part was accessible.

The nerve repair was performed in the shortest distance possible, with tension-free coaptation either directly or using a nerve graft. Nerve grafts were obtained from the sural nerve; they were cleared of unnecessary connective tissue and were sectioned into appropriate lengths. Fibrin glue was used to fix the grafts to the proximal root stumps. Once the fibrin glue had solidified, any excess was sharply trimmed and the root-graft junctions were inspected.

Postoperative management: following the primary reconstructions, patients remained in the hospital for a period of 24-48 h. The arm was placed in a splint immobilized to the chest. During this time, the family underwent training by the occupational therapy and nursing staff of the brachial plexus team to optimally manage postoperative care.

Follow-up was then arranged after 3 weeks, with removal of the splint. The patient was started on an aggressive physical therapy regimen focusing on keeping the joints supple and preventing contractures. Patients were then evaluated at 3-month intervals for a period ranging from 18 to 30 months, given that nerve regeneration should have occurred at least to the level of the deltoid, biceps, and triceps.

The first evidence of recovery was usually improved shoulder movement as the supraspinatus started to recover at about the third to fourth month postoperatively. Functional assessments of patients were then performed at every follow-up visit. Patients were photographed and video was used to record the grade of muscular function.

For shoulder abduction, the modified Gilbert six-stage system was used: stage 0, no abduction; stage 1, abduction angle less than 15°; stage 2, between 45 and 90°; stage 3, between 90 and 120°; stage 4, between 120 and l60°; and stage 5, normal. If the elevation angle was greater than 120°, it was considered a good result; between 120 and 90° was considered a fair result; and less than 90° was defined as a poor result [Figure 1],[Figure 2],[Figure 3] and [Figure 4].
Figure 1:

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Figure 2:

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Figure 3:

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Figure 4:

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For shoulder external rotation, the patient was asked to place the hand on the occipital region. A good outcome is indicated when the hand can touch the occipital region (shoulder external rotation ≥90°), a fair outcome is indicated when the hand can reach the ear (shoulder external rotation 60-90°), and a poor outcome is indicated when the hand is at a line of prechest or preface (shoulder external rotation <60°).

Results were collected, tabulated, and analyzed statistically using an IBM compatible personal computer with SPSS statistical package, version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. USA). Data were expressed using descriptive statistics, namely, the mean, percentages, and so on. Univariate analysis was carried out to determine the influence of variables on the outcome. A probability value of less than 0.05 was considered significant.


  Results Top


OBPP was present more in males (60%) than females (40%); the age of the patients at the time of surgery ranged from 3 to 15 months, mean 5 months. Twenty-eight patients (93.33%) were delivered by normal vaginal delivery; two (6.67%) were delivered by assisted vaginal delivery with forceps and no patient was delivered by cesarean section. The birth weight of most of the patients was less than 4 kg, 21 patients (70%), and 9 patients (30%) weighed over 4 kg. The right side was more affected in 19 patients (63.33%) than the left side in 11 patients (36.67%), and the associated injuries in the current study were present in 16.67% of patients: fracture clavicle in three patients (10%) and fracture humerus in two patients (6.67%). In terms of the neurotization of SSN, intraplexal neurotization was performed using a nerve graft to C5 in 12 patients (40%) or extraplexal neurotization using the SAN directly in 18 patients (60%). The patients were followed after the operation at 3-month intervals for any further recovery or worsening of muscle strength. The SSN neurotization outcome by the SAN showed 94.4% good outcome and 5.6% fair outcome, which were better than the outcome by C5 root neurotization (66.7% good and 33.3% fair); these results were statistically significant (P = 0.04). There was no intraoperative or postoperative mortality. In this study, postoperative complications were encountered in five patients (16.67%), superficial infection in the neck wound and leg wound, and none of the patients needed ICU admission, blood transfusion, or developed hair loss or pressure sores from the splint of the head [Table 1] and [Table 2].
Table 1: Clinical data of the patients

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Table 2: Patients' distribution according to the postoperative outcome of neurotization of the suprascapular nerve

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  Discussion Top


OBPP leading to a handicapped upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgery may preclude reinnervation of the paralyzed muscles [4].

Most of these injuries are transient; patients recover functions spontaneously within the first 3 months of life. However, some injuries result in prolonged and persistent disability even after therapy and therefore they are considered for surgical treatments [8].

The resulting paralysis reflects the numbers of the affected roots, although there is no precise relationship between the root and a precise paralysis as most of the roots are overlapping [9].

The most common OBPP involves lesions to the upper trunk (C5-C6), with or without injury to the C7 nerve root. C8-T1 roots are rarely affected [8]. The most vulnerable part of the plexus is the upper trunk if the injury reaches the lower plexus; the injury of the upper plexus becomes more severe [10].

In an attempt to recover the function of the affected limb, a number of different techniques have been proposed for brachial plexus reconstruction, including neurolysis, nerve reconstruction (repair or grafting), neurotization, tendon transfer, free muscle transplantation, and nerve root reimplantation [11].

There is no standardized surgical protocol determining the best treatment to be offered to patients sustaining brachial plexus injuries, and the operative strategy is mainly based on the surgeon's own experience [12]. The improved modern-day outcome of brachial plexus reconstruction, even with severe degrees of palsies involving root avulsions, is a result of many factors: first, the advent of microsurgical techniques and pediatric anesthesia, second, a better understanding of the nature of brachial plexus injuries, and third, the extensive research on surgical techniques [13].

Neurotization is an effective treatment option for the restoration of elbow and shoulder function in brachial plexus palsy. Early intervention and postoperative rehabilitation allow for the recovery of shoulder and elbow function in most patients [11].

Bertelli and Ghizoni [14] considered that the best outcome of neurotization can be expected in short denervation times and in the presence of proximal healthy roots.

Successful SSN neurotization will lead to recovery of the infraspinatus muscle for external rotation and the supraspinatus muscle for abduction. In this study, the SSN neurotization outcome by the SAN showed a statistically significant (94.4%) good outcome and (5.6%) fair outcome, which were better than outcome by C5 root neurotization (66.7% good and 33.3% fair); this difference was because neurotization by the SAN was performed directly through one site of suturing of nerve endings whereas neurotization by the C5 root was performed using a nerve graft through two sites of suturing of nerve endings, which may have affected its outcome.

Pondaag et al. [15], in a study carried out in 2005, reported the results of SSN neurotization in 86 patients by means of neurotization from C5 or the SAN; they found that there was no statistically significant difference between the results of C5 neurotization to the SSN and SAN neurotization to the SSN, although the results from nerve C5 neurotization tended to be slightly better. Also, Marcus and Clarke [16] found no significant difference between the results of C5-SSN neurotization and SA-SSN neurotization. El-Gammal et al. [17], found in their series that C5-SSN neurotization and SAN-SSN neurotization, 50 versus 35.2%, respectively; however, a statistical comparison between the two groups could not be carried out because of the small number of cases. In contrast, Gu et al. [18], reported that the extraplexal neurotization procedure was better and seemed quantitatively stable, and originally independent outflow from the SAN may reduce the extent of contraction between the external and internal rotators of the shoulder. However, Flores [12], reported that neurotization of the accessory to the SSN for restoration of shoulder abduction proved to be unreliable for restoration of functional abduction of the arm if used as the solely transfer.

In this study, there was no intraoperative or postoperative mortality as in the series of La Scala et al. [19]. No intraoperative complications were encountered in comparison with the work of La Scala et al. [19]; they reported an overall incidence of intraoperative morbidity of 12.2%. Birch et al. [10], in their series, reported phrenic nerve injury in 2% of cases (one of these infants required plication of the hemidiaphragm). This particularly serious complication is life threatening and utmost care is needed in defining and protecting the nerve. This may have been because of the small number of our patients, careful microdissection, or routine intraoperative use of a nerve stimulator.

In this study, postoperative complications were encountered in five patients (16.67%) in comparison with the work of La Scala et al. [19]; they reported an overall incidence of postoperative complication rate of 30.4%. The patients who presented with superficial infection in the neck wound and leg wound were managed with daily dressing and antibiotics. This is in agreement with Aydin et al. [20], who reported a superficial infection in 12.5% of patients with a neck incision, but Birch et al. [10], reported this in only 2% of cases. None of the patients needed ICU admission or blood transfusion; this is in agreement with the results of Aydin et al. [20]. None of the patients developed loss hair or pressure sore from the splint of the head, whereas Birch et al. [10], reported this in 2% of cases and Aydin et al. [20], reported this in 16.67% of cases. This complication can be avoided by good cotton padding under the splint and ensuring that the splint is not very tight over the head.


  Conclusion Top


Neurotization has broadened the reconstructive options for OBPP. Both SAN and C5 root neurotization to the SSN nerve are reliable options for shoulder reinnervation in infants with OBPP, but SAN direct neurotization without an interpositional nerve graft yields better results than using C5 root neurotization with an interpositional nerve graft.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Thatte M, Mehta R. Obstetric brachial plexus injury. Indian J Plast Surg 2011; 44 :380-389.  Back to cited text no. 1
    
2. Birch R. Invited editorial: obstetrical brachial plexus palsy. J Hand Surg Eur 2002; 27 :3-8.  Back to cited text no. 2
    
3. Narakas A. Thoughts on neurotization or nerve transfer in irrepairable nerve lesions. Clin Plast Surg 1984; 11 :153-159.  Back to cited text no. 3
    
4. Anil B, Ashok K, Piyush D, et al. Nerve reconstruction: a cohort study of 93 cases of global brachial plexus palsy. Indian J Orthop 2011; 45 :153-160.  Back to cited text no. 4
    
5. Gilbert A, Brockman R, Carlioz H. Surgical treatment of brachial plexus birth palsy. Clin Orthop Relat Res 1991; 264 :39-44.  Back to cited text no. 5
    
6. Samardzic M, Rasulic L, Grujicic D. Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 2000; 46 :93-103.  Back to cited text no. 6
    
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10.1Birch R, Ahad N, Smith S. Repair of obstetric brachial plexus palsy. J Bone Joint Surg 2005; 87 :1089-1095.  Back to cited text no. 10
    
11.1Dw Y, Kim M, Jung Y, Kim S. Neurotization from two medial pectoral nerves to musculocutaneous nerve in a pediatric brachial plexus injury. J Korean Neurosurg Soc 2012; 52 :267-269.  Back to cited text no. 11
    
12.1Flores L. Brachial plexus surgery. The role of the surgical technique for improvement of the functional outcome. Arq Neuropsiquiatr 2011; 69 :660-665.  Back to cited text no. 12
    
13.1Mohammad-Reda A. Early post-operative results after repair of traumatic brachial plexus palsy. Turk Neurosurg 2013; 23 :1-9.  Back to cited text no. 13
    
14.1Bertelli J, Ghizoni M. Reconstruction of complete palsies of the adult brachial plexus by root grafting using long grafts and nerve transfers to target nerves. J Hand Surg 2010; 35 :1640-1646.  Back to cited text no. 14
    
15.1Pondaag W, de Boer R, Malessy M, et al. External rotation as a result of suprascapular nerve neurotization in obstetric brachial plexus lesions. Neurosurg J 2005; 57 :530-537.  Back to cited text no. 15
    
16.1Marcus J, Clarke H. Management of obstetrical brachial plexus palsy; evaluation, prognosis and primary surgical treatment. Clin Plast Surg 2003; 30 :289-306.  Back to cited text no. 16
    
17.1El-Gammal T, El-Sayed A, Kotb M, et al. Total obstetrical brachial plexus palsy: results and strategy of microsurgical reconstruction. Microsurgery 2010; 33 :1-9.  Back to cited text no. 17
    
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20.2Aydin A, Mersa B, Erer M, et al. Early results of nerve surgery in obstetrical brachial plexus palsy. Acta Orthop Traumatol Turc 2004; 38 :170-177.  Back to cited text no. 20
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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