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Medial branch spinal accessory (XI) nerve transfer to Suprascapular nerve through a posterior approach

    Overview

    Learn the Medial branch spinal accessory (XI) nerve transfer to Suprascapular nerve through a posterior approach surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Medial branch spinal accessory (XI) nerve transfer to Suprascapular nerve through a posterior approach surgical procedure.
    The spinal accessory (XIth) nerve transfer to the suprascapular nerve is a reliable technique for restoring function to the supraspinatus and the infraspinatus following a complete injury to the C5 nerve root. The technique was traditionally performed using the lateral branch of the XIth nerve through an anterior approach at the time of neck exploration for a brachial plexus injury and nerve co-aptation was in the anterior wound and proximal to the supra scapular notch. Critical review of the results demonstrates some patients having little functional recovery and generally poor restoration of external rotation. The introduction of a posterior approach allows co-aptation to be performed closer to the paralysed muscles and the SSN can be decompressed at the notch and inspected for damage. Regenerating nerves are generally temporarily more swollen and may auto compress themselves at tight anatomical structures. In the high energy brachial plexus injury the relative tether of the SSN at the supra scapular notch by the supra scapular ligament renders the nerve liable to a traction injury and a rupture or neuroma in continuity may be overlooked when the transfer is performed using the anterior approach. The medial XIth nerve branch is used as the donor nerve in the posterior approach which avoids denervation of the lateral trapezius seen in the anterior approach. The lateral trapezius is important for shoulder elevation and is important for positioning of the arm in cases of complete paralysis of the supraspinatus and deltoid muscles seen after C5 injury. Typically the XI to SSN transfer is combined with transfer of a radial nerve branch from triceps to the axillary nerve in complete C5 lesions. My preferred technique for XI to SSN transfer is using the posterior approach. The procedure is technically more demanding than the anterior approach but with with a co-aptation performed closer to the target and the other advantages already discussed, it is difficult to justify not using this technique.

    Indications

    INDICATIONS:
    The main indication for a nerve transfer to the suprascapular nerve (SSN) is following a C5 avulsion injury. In this situation there is no proximal nerve stump available for grafting and so a nerve transfer provides a reliable way of restoring innervation to the denervated muscles. The transfer is performed close to the motor point of the supraspinatus and therefore reinnervation is rapid. The same technique can be used for upper trunk ruptures with late presentation where graft reconstruction of the upper trunk is unlikely to restore motor function to the supraspinatus due to the time-distance phenomenon of nerve regeneration. In cases where the upper trunk has been grafted early but failed to recover, this nerve transfer can be used as a salvage procedure.
    The timing of nerve transfer is critical and generally speaking the earlier the transfer is performed the better the results. In avulsions and other un-reconstructable lesions, no recovery can be expected and early nerve transfer is indicated. In cases where there is a potential for spontaneous recovery, a period of observation is usual. Nerve transfer can be deferred in this instance, but needs to be performed ideally at between 6 to 9 months following the injury, if successful reinnervation of the supraspinatus and infraspinatus is going to be achieved by 12 to 18 months.
    I also use this technique for other causes of C5 nerve root dysfunction. In cases of brachial neuritis (Parsonage-Turner syndrome) with no supraspinatus recovery by 9-12 months, this technique can be employed for reinnervation as long as the XIth nerve is functioning. There is a small risk of a further episode of neuritis as a response to surgery. The aetiology is poorly understood but probably represents an autoimmune response to viral insult in a sensitised individual.
    I also use this technique for restoration of function in patients with a non-reversible motor radiculopathy associated with degenerative cervical disc disease. The timing is controversial because, unlike traumatic avulsions, typically these lesions are incomplete and may have some potential for spontaneous regeneration. Such incomplete lesions may exhibit longer windows for surgery due to the fact that intact axons within the nerve may auto “babysit” the motor end plates and collaterally sprout to denervated muscle fibres. There may be too few axons for function but the paralysed muscle may be able to respond to reinnervating axons for longer than the 12 months typical of a complete peripheral nerve injury.
    SYMPTOMS & ASSESSMENT:
    In a C5 avulsion there is loss of shoulder abduction and external rotation with complete paralysis of the supraspinatus, infraspinatus, deltoid and teres minor. Levator scapulae and the rhomboid muscles are generally paralysed because the dorsal scapular nerve takes origin proximally on the C5 root. If these 3 medial scapula muscles are preserved it may suggest that the C5 root is ruptured, however these muscles may receive innervation from C4 in a pre-fixed brachial plexus and so integrity of these muscles does not guarantee that a proximal C5 nerve stump is available for grafting.
    In cases of C5 and C6 loss there is complete loss of the above muscle plus additional loss of the subscapularis, teres major, clavicular head of pectorals major, biceps, brachial and brachioradialis. Serratus anterior will be weak but there is still some innervation through the C7 root.
    The shoulder will be held in adduction and internal rotation (C5) with the elbow in the extended position (C5 and C6). Functionally this is devastating for patients because in a partial plexus injury the intact forearm and hand cannot be positioned in space to allow environment interaction. Nerve transfer reconstruction is ideal for this injury because reconstruction is performed using donor expendable nerve branches or redundant motor fascicles from within intact nerves originating from the lower plexus and traversing the neck and shoulder regional in close proximity to the paralysed muscles before reaching their targets in the forearm and hand. This anatomical relationship renders them ideal for functional reinnervation of the shoulder and elbow. In contrast isolated lower brachial plexus injuries with preserved shoulder and elbow function are less suitable for nerve transfer reconstruction because the reinnervation distances are longer from the donor motor branches.
    Sensory loss of the outer upper arm to the elbow (C5) and the radial forearm and hand palmar and dorsal aspects (C6) is readily demonstrated.
    Passive range of motion of the shoulder must be assessed because longstanding loss of C5 function results in adduction and internal rotation contractures. Therapy should be directed to restoring passive range and the shoulder can be manipulated at the time of anaesthesia for the nerve transfer surgery. Early reinnervation with weak muscles are not able to maintain the range achieved through manipulation and therapy and so an extended rehabilitation is required until there is sufficient power in the recipient muscles to maintain range of motion. As the nerve transfer recipient muscle strength increases the patient can work to and gradually beyond the range achieved with physiotherapy. Further improvements in strength, range off motion and function are expected to 2 years and beyond.
    INVESTIGATION:
    MRI scan of the brachial plexus may demonstrate a pseudomeningocoele confirming the presence of a nerve root avulsion. High resolution MRI scan of the cervical spine may demonstrate cord displacement, disruption of the intra-dural ventral and dorsal rootlets, signal change within the cervical spinal cord due to rootlet avulsion and oedema. MRI scan of the brachial plexus may show oedema in root ruptures and loss of nerve continuity, however it cannot assess the quality of the proximal nerve root nor the size of the gap to be reconstructed. MRI scan of the cervical spine in degenerative nerve root compression is important to exclude a neurosurgical target for nerve decompression.
    When nerve transfer surgery is undertaken for degenerative nerve root compression it is important to establish that the rotator cuff is anatomically intact. This patient group is generally older than those patients who sustain high-energy supraclavicular traction brachial plexus injuries. In the older patients with degenerative root compression, loss of the C5 motor function with paralysis of deltoid may unmask a previously undiagnosed rotator cuff tear. Nerve transfer reconstruction of function to the rotator cuff should therefore only be considered in these cases after careful consideration and discussion of the feasibility of subsequent rotator cuff repair with a shoulder specialist. Otherwise attention should be given to deltoid reconstruction through nerve transfer to the axillary nerve and if needed a reverse shoulder replacement can be employed for pain and dysfunction from rotator cuff arthropathy should the grade of deltoid recovery be sufficient to power the arthroplasty.
    Neurophysiological investigations including electromyography are essential components of the preoperative assessment of patients prior to nerve transfer surgery. Electromyography (EMG) can assess the extent of denervation of the potential target muscle as well as the integrity of the function within the donor. In cases of degenerative nerve root compression the window for reconstruction may be longer than the 12 months suggested for complete peripheral nerve lower motor neurone lesions. In a research setting quantitative assessment of the motor unit size using EMG may identify patients suitable for targeted reinnervation beyond the typical 12-month window. Non-functional residual axons in the target nerve may collaterally sprout within the muscle, increasing the motor unit size and providing an auto “babysitting” function, potentially rendering the muscle responsive to new incoming motor axons for longer than complete peripheral nerve injury, extending the window for reconstruction beyond 12 months.
    OPERATIVE ALTERNATIVES:
    The alternatives to nerve transfer surgery include musculo-tendinous transfer. The trapezius may be transferred to the greater tuberosity of the humerus to improve shoulder abduction and the contralateral trapezius may be transferred to the infraspinatus tendon to improve external rotation. An ipsilateral functioning latissimus doors can also be transferred for external rotation. The function of the shoulder achieved through musculo-tendinous transfer is limited in terms of quality and power.
    An alternative strategy is glenohumeral arthrodesis to provide stability for a patient with severe paralysis and allow the arm to be functional. Arthrodesis requires periscapular muscle activity ideally in the serratus anterior, pectoralis major, pectoralis minor, levator scapulae and rhomboids.
    NON-OPERATIVE ALTERNATIVES:
    Non-operative treatment strategies include bracing of the shoulder girdle to allow sufficient stability such that functional elbow, forearm, wrist and hand movement can be achieved. In patients not suitable for surgical reconstruction the use of a gravity assist elbow and forearm platform can compensate for lack of shoulder function when undertaking office based activities. Advances in robotic technology allow the use of exoskeletons for functional use of a limb and compensation for the segmental paralysis seen in C5 and C5/6 paralysis. However exoskeleton devices are not widely available and currently too expensive for mainstream adoption.
    CONTRAINDICATIONS:
    The main contraindication to nerve transfer surgery is a muscle that has been denervated for too long, typically between 9 and 12 months for a lower motor neurone complete injury. Patients must be able to understand the planned treatment and be able to comply with the extensive period of post operative rehabilitation necessary to achieve a functional outcome.



    Setup

    The patient is placed in the lateral position with slight forward roll and the operated side uppermost. The torso should be supported with posts posteriorly at the lower lumbar spine and anteriorly at the anterior superior iliac spines. The operated arm should be supported in a gutter. An alternative position is to perform the operation in the prone position. I avoid this position because of a concern regarding traction on the brachial plexus and the added anaesthetic challenges including the need for neuromuscular blockade at induction.
    General anaesthesia is required and either short acting or no neuromuscular paralysis is essential. Intra-operative nerve stimulation is a mandatory requirement for this procedure and successful nerve transfer can only be achieved after confirmation of normal stimulation in the donor nerve and absent stimulation in the recipient.
    I use a regional anaesthesia block needle with stimulation provided by anaesthetic nerve stimulator which provides a range of stimulation from 0.02mA to 5mA at a frequency or 60Hz. The needle is covered with an arthroscopy camera drape and the circulating team activate the stimulator and make the adjustments as requested by the operating team. The patient requires an electrode outside the operative field to complete the circuit.
    During dissection and localisation of nerves a Mixter (90 degree fine pointed clip) is a convenient way of passing tagging and insulating colour-coded surgical rubber sloops around nerves. These rubber sloops allow gentle traction on a nerve for the neurolysis and mobilisation and minimise handling of the epineurium. They provide an insulation against cross stimulation to adjacent nerves when used to lift a nerve during assessment with higher stimulation thresholds.
    An operating microscope should be available. A set of surgical micro-instruments is essential for performing nerve transfer surgery. Neurotomes enable clean nerve transection without crush injury and serrated microsurgical scissors are useful for debriding epineurium. The co-aptation is performed using curved needle holders and 8’0 or 9’0 monofilament non-absorbable suture depending on the diameter of the nerve transfer at the co-aptation site.
    TisseelTM is used as a biological tissue glue (fibrin) to support the co-aptation site and minimise the need for sutures which may distort the nerve ends and create scar at the neurorraphy site.

    Operation – 1

    The patient is positioned in the right lateral position with the left shoulder uppermost. The upper arm is supported on a gutter and for this part of the procedure the forearm is supported on a padded Mayo table. The whole limb is prepared including the anterior and posterior aspects of the shoulder, the posterior neck, the back to beyond the midline and inferiorly beyond the tip of the scapula. The arm and hand must be visualised when undertaking nerve stimulation to confirm the nerve anatomy and prevent inadvertent iatrogenous nerve injury.

    Anatomical landmarks are marked including the spine of the scapula, the acromion, the coracoid and the inferior pole. In this case there is a planned concomitant procedure for transfer of a radial nerve branch from triceps to the axillary nerve and this will be described separately.

    Measurements should be taken from the midline (spinous processes) to the acromion lateral border. the medial branch of the spinal accessory nerve (XI) is located 40% of the way from medial to lateral between these landmarks and should be marked.
    The suprascapular nerve (SSN) lies 50% of the way between the medial border of the scapula and the lateral border of the acromion. This is marked to guide the surgical incision.

    The skin is opened in a transverse incision 8cm long parallel to the scapula spine and 2-3cm superiorly. The deep fascia is opened to the trapezius muscle using a monopolar diathermy epitome blade. This plane is vascular and careful haemostasis is necessary before proceeding with the deep dissection to avoid inadvertent traction injury to the XI nerve as trapezius is split along its oblique superior and lateral fibres.

    The oblique fibres of the trapezius muscle are exposed (T).
    Retraction is maintained with a Travers retractor.

    The fibres of the trapezius are split centred on the cutaneous marking for the medial branch of the XIth nerve. Develop the plane with Jamieson scissors and then gentle finger blunt dissection identifies a relatively avascular cleavage plane in the direction of the oblique fibres.

    The XIth nerve lies in the fat deep to the trapezius. Small branches penetrate to supply the deep surface of the muscle. These proximal branches can be preserved. The main distal branch of the medial XIth nerve should be identified with careful dissection in the fat. It lies in close proximity with a vascular pedicle. Nerve stimulation can be used at high stimulation (2mA) to try to identify the nerve branch in the fat. The stimulation should then be turned down as the nerve is mobilised. Normal stimulation directly on the epineurium will be at 0.1mA.

    A Mixter (fine 90 degree pointed vessel clip) is passed deep to the XIth nerve and the nerve is mobilised so that a surgical sloop can be passed around it.

    A blue sloop is passed deep to the XIth nerve. Note that the sloop end is delivered flush to the Mixter jaws to that there is no tether or inadvertent traction as it is pulled under the nerve. Care should be taken when closing the jaws that no soft tissue or epineurium on the deep surface of the nerve is caught in the jaws during this manoeuvre which is performed blindly as it is deep to the nerve.

    Now that the distal part of the medial branch of the XIth nerve is isolated in a sloop it can be stimulated to confirm contraction of the lower trapezius at a normal stimulation threshold (0.1mA).

    Once tagged with the blue sloop there is no further dissection of the XIth nerve in order to protect it from injury during exposure of the target SSN. Standard practice when undertaking nerve transfer surgery is to first identify the recipient and stimulate to demonstrate no function prior to exposure of the donor. The rationale for this is to avoid inadvertent injury to the donor by unnecessary exposure should the target recipient nerve have some preserved function and the procedure is therefore abandoned. In this transfer the XIth nerve must be first identified as it is seen during the deep dissection exposure of the target SSN. Avoiding excessive dissection and preventing traction injury by not placing a clip on the blue sloop are important steps. The fat pad (F) deep to the trapezius and overlying the suprascapular neurovascular bundle is seen in the lateral end of the wound.

    A swab is placed over the XIth nerve to further protect it from inadvertent injury. Care should be taken when repositioning the Travers retractor for the lateral SSN exposure. The fat pad has been moved inferiorly and medially and the clavicle (C) is seen in the upper part of the wound, the coracoclacicular ligaments (CL), the base of the coracoid process (Co) in the deep wound and a view of the ossified suprascapular ligament (SL).

    This is the most challenging part of the operation because the three dimensional anatomy of the suprascapular notch is difficult to appreciate and changes with scapula position. My identification of the notch includes the following steps:
    Palpate the deep and posterior aspect of the clavicle in the upper and lateral wound
    Deep and distal to the clavicle palpate the coracoid base
    Trace the contour of the bone from the coracoid base along the upper border of the scapula in a medial direction
    The ligament is medial to the coracoid base and may be ossified
    The omohyoid muscle inserts on the ligament and can be visualised
    The suprascapular artery lies in the fat superficial to the ligament
    The supraspinatus muscle and fascia lies distal to the ligament and can be palpated
    Sloop the artery and reract medially
    Divide the omohyoid or elevate the insertion with a periosteal elevator
    Dissection the fat proximal to the ligament using scissors opened in an oblique direction aimed towards the ipsilateral scapula inferior pole
    The nerve is identified proximal to the fascia and can be protected with a sloop
    In a case of rupture the proximal SSN may not be identified easily and therefore expose the supraspinatus muscle distal to the upper border of the scapular and identify the nerve in the supraspinous fossa and trace superiorly.

    The suprascapular ligament (SL) is ossified in this patient. The omohyoid muscle (O) inserts in the ligament and has been moved medially with careful use of a periosteal elevator. The suprascapular nerve (SSN) lies in the fat and passes deep to the ligament. The suprascapular artery usually passed superficial to the ligament with veins and care should be taken exposing the ligament as tearing of these vessels can cause bleeding and the damaged vessel can retract deep necessitating extensile exposure and risking damage to either the donor or recipient nerves during attempts to gain vascular control. Even minor bleeding can render the mircosurgical neurorraphy extremely challenging in this deep part of the wound.

    A red sloop has been passed carefully around the suprascapular artery. A yellow sloop will be used to tag the SSN prior to release of the ossified suprascapular ligament.

    The yellow sloop is passed deep to the SSN using a Mixter.

    After further release of the notch the SSN can be lifted free and nerve stimulation used to confirm that there is no residual function.

    SSN – Suprascapular nerve
    SSA – Suprascapular artery

    A damp swab has been placed deep to the suprascapular ligament (SL) to protect the SSN and the suprascapular artery in preparation for osteotomy and resection of the ossified suprascapular ligament. In young patients the ligament is usually firm and flush with the bone but can be cut with sharp dissection using a scalpel. It is normally not necessary to place a swab deep to the ligament because there is a risk of causing an injury to the suprascapular nerve. In this case the ligament was ossified and there was sufficient space to place the swab deep to to the ligament to illustrate the exposure and provide some protection during the osteotomy of the ossified ligament. This is not normally required and could injure the SSN if not placed with care.

    Long-handled fine-tipped bone nibblers are used to remove the ossified SL.

    The ossified ligament has been partially resected and the nerve can be lifted into the opening of the notch. Note that the lateral aspect of the notch and ligament is still compressing the distal SSn which is tightly adherent to the bone as it passes posteriorly and laterally into the supraspinous fossa.

    The SSN is sectioned proximal to the notch with scissors so that sufficient length may be mobilised to the wound for the co-aptation. In cases where there is a neuroma of the SSN at the notch or a rupture there is less length available for transfer which will have to be performed deeper in the wound with care taken mobilising the donor XIth nerve to ensure sufficient length for transfer.

    The distal medial branch of the XIth nerve is neurolysed to gain sufficient length for direct transfer to the SSN. The nerve is sectioned distally.
    REMEMBER: “Donor distal and recipient proximal” when undertaking the neurotomies.
    I use scissors at this point but neurotomes can be used if access is not a problem or later to trim the nerve end prior to co-aptation and ensure fresh clean nerve ends.

    The two nerve ends are laid on a piece of microsurgical background material. There is fresh bleeding from both ends confirming healthy nerve. Do not use diathermy – the bleeding will stop and the clot can be removed under the microscope.

    The operating microscope is brought in to position and adjusted.

    A monitor screen is available for the scrub nurse and assistant. A second microsurgery assistant is not possible for this co-aptation because of the position of the scope angled distally and the patients arm blocks access for the assistant.

    Operation – 2

    Following removal of the clot and trimming of the nerve ends, the neurorraphy is completed using microsurgical suture. In this case the nerve diameter is sufficient for 3 evenly spaced 8’0 nylon sutures placed 120 degree apart around the circumference of the nerve ends. Care should be taken to prevent distortion of the nerve ends and overlapping of fascicles.

    The completed tension-free neurorraphy seen down the microscope prior to application of TisseelTM fibrin glue.

    The neurorraphy prior to TisseelTM application.

    TisseelTM fibrin glue is supplied frozen and should be defrosted to 37 degrees centigrade. There are 2 syringes: One contains fibrinogen and one thrombin. The fluids are mixed at the tip of a specially designed double barrelled nozzle and applicator. Between uses the fibrin clot blocks the nozzle tip and spare ones are available for tip exchange between uses if several applications are required in one patient.

    TisseelTM is applied around the neurorraphy to protect the co-aptation site of the nerve transfer.

    The microsurgery background material can be rolled around the neurorraphy site to completely enclose the co-aptation.

    The two ends of the background material are held together for 30 seconds whilst the TisseelTM activates and the fibrin clot forms around the co-aptation site of the nerve transfer.

    More TisseelTM glue is added to support the nerve transfer proximally and distally to prevent inadvertent rupture of the neurorraphy. The Tisseel is rapidly reabsorbed within 2 weeks and provides only temporary support whilst the nerve ends heal.

    The trapezius split is repaired wit interrupted vicryl 3’0 sutures and then the deep fascia closed with vicryl 2’0. The skin deep layer is closed with Monacril 3’0 interrupted sutures before a subcuticular closure of the dermis.

    The closed wound has long acting local anaesthetic infiltration to the wound edges and then broad steristrips are applied to support the wound.

    A waterproof dressing with absorbent pad is applied to the wound. The wound should be kept clean and dry for 7 days after which the patient can shower then replace the dressing. A polysling is applied to the upper limb with a torso strap around the waist before the patient wakes from surgery. The polysling and torso strap should be maintained for 3 weeks to prevent excessive passive movement at the shoulder.

    Post Operative

    This procedure is usually performed in combination with nerve transfer from the radial nerve (triceps branch) to the axillary nerve (C5 reconstruction) and sometimes with a nerve transfer to biceps for brachialis (C5 and C6 reconstruction). These procedures will be featured elsewhere in OrthOracle. The arm is placed in a polysling with a supplementary torso strap to prevent abduction and external rotation.
    The wound should be kept covered for 2 weeks with the patient permitted to shower at 7 days and replace the dressing.
    During this phase the patient is encouraged to maintain isometric contraction of the donor muscle in the sling and to visualise the combination of trapezius activation and shoulder abduction and external rotation.
    Nerve transfer rehabilitation involves a 6-phase programme of activity developed at the Centre for Nerve Injury and Paralysis, Birmingham, UK.
    Phase 1 – Pre-operative phase: Education and donor optimisation. Introduction to trophic stimulation and the concept for functional electrical stimulation (FES).
    Phase 2 – Protection phase: During the immediate post-operative period the nerve transfer is protected from inadvertent injury with the arm immobilised. Isometric contraction of the donor and visualisation of the combination donor-recipient action is performed during this period which typically lasts 3 weeks.
    Phase 3 – Prevention phase: During this phase the arm is mobilised and neural gliding is commenced. Joint range of motion exercises (active and passive) are commenced to prevent joint contractures developing. The isometric exercises are continued and isotonic and eccentric exercises are commenced for the donor muscle to maintain function and restore strength. Functional stimulation can be commenced on the donor muscle. Trophic stimulation can be maintained on the recipient muscle.
    Phase 4 – Power phase: During this period the donor muscle is strengthened and the recipient muscle starts to respond. Typically the first sign of reinnervation is a tender muscle squeeze sign due to small fibre reinnervation. Typically this is 3 months following transfer but is affected by the distance of the co-aptation from the recipient motor point.Visible flickers of contraction follow within 6 weeks and donor activation potentiate the recipient response. FES continues and the phase lasts for approximately 6-12 months during which useful motor grade returns: Medical Research Council – (MRC) Grade 3-4.
    Phase 5 – Plasticity: During this phase the patient works on activation of the recipient muscle without activation of the donor. This phase can overlap with phase 4 and is guided by a therapist specialised in nerve transfer rehabilitation.
    Phase 6 – Purpose: During this phase the patient introduces function tasks discussed as objectives during the pre-operative phase. This period of training is tailored to the individual and includes work hardening. Improvements are typically found in power and functional performance for at least 2 years following nerve transfer surgery.
    Outcomes assessment can be with MRC scales but becaus eof the huge functional variation within MRC Grade 4, I prefer absolute muscle testing with digital myometry and comparison with the contralateral limb. In addition fatigue testing and functional scores are important. The EQ5D, DASH and the BrAT scores are in common use in assessing upper limb function after brachial plexus injury. The Canadian Occupational Performance Measure (COPM) is an ideally suited tool to assess patient specific objectives and outcomes.

    Recommended Reading

    The technique of transfer of the XIth nerve to the SSN is not new. Critical appraisal of the results of an anterior transfer using the lateral branch demonstrate reasonable shoulder abduction but relatively poor external rotation. I prefer 2 transfers for abduction and 2 transfers for external rotation (posterior approach XI medial branch to SSN; Triceps medial head branch to axillary nerve). This technique reinnervates supraspinatus, infraspinatus, deltoid and teres minor. Useful (strong MRC grade 4) function can be achieved in the majority of cases if patient selection guidelines are adhered to as discussed earlier in this review. This approach is supported in the literature with a double nerve transfer achieving improved shoulder abduction MRC Grade 4 in 74% compared to 35% with a single nerve transfer and 46% of grafts alone. There is bias as the grafts are only possible in ruptures of the upper trunk and the injury patterns may be different. The range of external rotation was also grater with a double nerve transfer in this series. by Wolfe et al in 2011. Papp et al define the need for distal decompression after proximal nerve injury in their paper from 1998.
    Garg R, Merrell GA, Hillstrom HJ, Wolfe SW. Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis. J Bone Joint Surg Am 2011 May 4;93(9):819-29. doi: 10.2106/JBJS.I.01602.
    Leechavengvongs S, Malungpaishorpe K, Uerpairojkit C, Ng Cy, Witoonchart K. Nerve transfers to restore shoulder function. Hand Clin 2016 May;32(2):153-64. doi: 10.1016/j.hcl.2015.12.004.
    Yang LJ, Chang KW, Chung KC. A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury. Neurosurg 2012 Aug;71(2):417-29; discussion 429. doi: 10.1227/NEU.0b013e318257be98.
    Schoeller T, Otto A, Wechselberger G, Pommer B, Papp C. Distal nerve entrapment following nerve repair. Br J Plast Surg 1998 Apr;51(3):227-9; discussion 230.
    Yang LJ, Chang KW, Chung KC. A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury. Neurosurg 2012 Aug;71(2):417-29; discussion 429. doi: 10.1227/NEU.0b013e318257be98.

    Reference

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