Reconstruction of Complete Palsies of the Adult Brachial Plexus by Root Grafting Using Long Grafts and Nerve Transfers to Target Nerves

Purpose We report on the results we obtained with reconstruction for total paralysis of the brachial plexus using long nerve grafts that connect nonavulsed roots to the musculocutaneous and radial nerve. Nerve transfers were performed to restore function of the suprascapular nerve, triceps long head, and pectoralis major muscle. Methods We studied 22 young adults with complete brachial plexus palsy who had surgical repair an average of 5 months after trauma. Nerve grafts connected the C5 root to the musculocutaneous nerve. The C6 root was connected by grafts to the radial nerve. When the C6 root was avulsed, the levator scapulae motor branch was connected by grafts to the triceps long head motor branch. In 13 patients, the platysma motor branch was transferred to the medial pectoralis nerve through a long nerve graft. The suprascapular nerve was repaired through transfer of the accessory nerve. Outcomes were assessed an average of 27 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale. Results All but one patient recovered some shoulder abduction, with a mean range of recovered shoulder abduction of 57 degrees. Pectoralis major reinnervation was observed in 9 of the 13. Twenty patients recovered full elbow flexion and achieved at least grade M3 strength. Among the 10 patients in whom the C6 root was grafted to the radial nerve, 4 patients recovered active elbow extension with biceps co-contraction. All patients in whom the levator scapulae nerve was connected to the triceps long head recovered active elbow extension, albeit weak. Double lesions of the musculocutaneous nerve were identified in 4 patients. Conclusions Accessory to suprascapular nerve transfer, levator scapulae nerve transfer to the triceps long head and C5 root grafting to the musculocutaneous nerve is now our preferred method of reconstruction in total palsies of the brachial plexus. (J Hand Surg 2010,35A:1640-1646. Copyright (C) 2010 by the American Society for Surgery of the Hand. All rights reserved.)