CLINICAL APPLICATION OF IPSILATERAL C7 NERVE ROOT TRANSFER FOR TREATMENT OF C5 AND C6 AVULSION OF BRACHIAL PLEXUS

Y.-D. GU, M.D.,* P.-Q. CAI, M.D., F. XU, M.D., F. PENG, M.D., AND L. CHEN, M.D.

We applied a nerve transfer, using the ipsilateral C7 nerve root to treat the C5 and C6 root avulsion of the brachial plexus. Four patients with C5 and C6 preganglionic injury were operated on with this new technique from 19982000. Transfer of the spinal accessory nerve to the suprascapular nerve was simultaneously done in 2 these patients. After a follow-up of 12.5 years, the muscle strength of elbow flexors recovered to M4 (Lovett) in all cases, shoulder abduction of >90 with external rotation of 3040 was gained in two cases, and that of 1545 with no external rotation in the 2 other two cases. No remarkable impairment was found in all

C7-innervated muscles except for decrease of muscle power of 1 grade (Lovett) in the short run. This new technique shows promise as an efficacious and safe treatment for C5 and C6 root avulsion of the brachial plexus. However, it should be applied prudently when incomplete injuries of the lower trunk are involved.

2003 Wiley-Liss, Inc.

MICROSURGERY

23:105108

2003

Neurotization

with healthy-side C7 nerve root for treatment of total root avulsion of the brachial plexus, as described previously,14 has proven an ecacious and safe surgery. As to the treatment for C5 and C6 root avulsion of the brachial plexus, we reported a procedure of transferring selective fascicles of the anterior division of the ipsilateral C7 nerve root to the anterior division of the upper trunk; the functional recovery of elbow exion has been satisfactory.5,6 On the basis of our previous work, we applied a new technique of using transfer of the ipsilateral C7 nerve root (whole root) for treatment of C5 and C6 root avulsion, for restoration of shoulder abduction and elbow exion. Results were satisfactory.

PATIENTS AND METHODS

All 4 patients were male, and their age varied from 2349 years, with an average of 32 years. The injured side was on the right in 2 cases.The injury was caused by traffic accident in 3 cases, and by stabbing in 1 case. Preoperative examination demonstrated a complete loss of muscle function innervated by the upper trunk of the
Department of Hand Surgery, Hua-Shan Hospital, Fu-Dan University, Shanghai, China *Correspondence to: Yu-Dong Gu, Department of Hand Surgery, Hua-Shan Hospital, Fu-Dan University, 12 Ulumuqi Middle Road, Shanghai, 200040 Peoples Republic of China. E-mail: yqay@soho.com Received 14 January 2002; Accepted 11 February 2003 Published online in Wiley InterScience (www.interscience.wiley.com). DOI:10.1002/micr.10113 2003 Wiley-Liss, Inc.

brachial plexus at the affected side in all patients. Phrenic nerve injury was found in all and spinal accessory injury in 2 cases, as shown in Table 1. Electromyography (EMG), neurophysiology with compound muscle action potential (CMAP), and somatosensory evoked potential (SEP) were performed in all cases and, based on the combined findings of our clinical examination, a diagnosis of C5 and C6 preganglionic injury was made. The brachial plexus was explored in the usual way, and dorsal ganglions of C5 and C6 were found in all cases. The C7 nerve root was dissected free, and its normality was confirmed by a perioperative neurophysiology test. C7 was then blocked with 1% procaine,1 and divided at the distal level of divisions. The anterior and posterior divisions of C7 were transferred to those of the upper trunk, and in 2 cases, the suprascapular nerve was neurotized with the spinal accessory nerve. The anastomosis was made with microsutures. Postoperative management included immobilization of the aected limb with a head-arm brace for 4 weeks, and medication with nerve nutrient drugs (vitamins B1, B6, and B12). Rehabilitation exercises and electric stimulation with a custom-made instrument were begun after immobilization.

RESULTS

At postoperative 1 week, the power of C7-innervated muscles decreased by 1 grade (Lovett) in comparison with preoperation levels. There was numbness in the

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Table 1. Clinical Data and Surgical Procedures*

Name 6 Yue Zeng Liu Sun

Age 23 49 35 23

Sex Male Male Male Male

Affected side Left Right Right Left

Cause Trafc accident Stabbing Trafc accident Trafc accident

Diagnosis Operative delay a, P, A b, P, A a, P a, P 2.5 months 2 months 5 months 50 days

Surgical procedure C7 nerve root C7 nerve root C7 nerve root Ac Sc C7 nerve root Ac Ss upper trunk upper trunk upper trunk upper trunk

Follow-up 22 months 30 months 24 months 12 months

7 *a, C5 and C6 preganglionic injury; b, C5 and C6 postganglionic injury; P, phrenic nerve injury; A, accessory nerve injury; Ac Ss, accessory nerve suprascapular nerve.

Table 2. Comparison of Muscle Strength of C7 Innervated Muscles Between Preoperative and Postoperative Condition* Lattismus dorsi Case 1 2 3 4 Preop M4 M4 M3 M3+ 1w post M3 M3 M3 M3 0.5y post M4 M3 M4 M4 Preop M4 M4 M3 M3 Triceps brachii 1w post M3 M3 M3 M4 0.5y post M4 M4 M4 M5 Extensor digitorum communis Preop M4 M5 M3+ M4 1w post M4 M4 M3 M4 0.5y post M5 M5 M4 M5

*Preop, preoperative; 1w post, 1 week after operation; 0.5y post, half a year after operation.

Table 3. Follow-Up Results of Shoulder Abduction, External Rotation, and Elbow Flexion Case 1 2 3 4 Follow-up (months) 22 30 24 12 Deltoid M2 M2 M3 M4 Supra and infraspinous M2 M1 M3 M3 Shoulder abduction 45 15 >90 >90 External rotation 10 0 40 30 Biceps M4 M4 M4 M4

thumb web in all cases (Table 2). A neurophysiology test showed that the amplitude and latency of CMAP was not significantly different from those from preoperation.7 At postoperative 6 months, however, muscles innervated by the C7 nerve root had recovered to normal in all cases, and the numbness in the thumb web disappeared in 2 cases, but was still present in the other 2 cases. Over the first period of 36 months after the operation, muscle contraction of the biceps and deltoid was found in all cases; in 1 case with the suprascapular nerve neurotized by the spinal accessory nerve, the supraspinous and infraspinous muscles could feel contracted. At 1230 months postoperatively, the biceps improved to M4 in all cases; a shoulder abduction of >90 and external rotation (in adduction) of 30 were gained in 2 cases with the spinal accessory nerve transfer, while in the other 2 cases with no extra spinal accessory nerve transfer, abduction of shoulder was only 30 on average, with hardly any external rotation (Table 3).
TYPICAL CASE

A man (case 4 in Table 1) who was injured in a motorcycle accident had a functional loss of the left

shoulder and elbow and was referred to our clinic 50 days after injury. Physical examination showed an absence of pricking pain at the innervation region of C5 and C6 (thumb and index finger), atrophy of the trapezius with M2 muscle power, atrophy of the biceps, deltoid, supraspinous, infraspinous, and brachiaoradialis with M0, and square shoulder deformity. The strength of the lattismus dorsi and triceps was M3, that of the sternal part of the pectoralis major and extensor digitorium communis was M4, and that of the intrinsic muscles and nger exor muscles was normal. Combined with electromyography and neurophysiology tests (SEP and CMAP), a diagnosis of C5 and C6 root avulsion of the brachial plexus was made. The plexus was explored, and the ganglions of C5 and C6 were found. A perioperative neurophysiology test showed unresponsiveness of the phrenic nerve, but a normality of C7, C8, T1, and the spinal accessory nerve. The middle trunk was then isolated, blocked with 1% procaine, and transected as far as possible. Transfer of the middle trunk to the proximal part of the anterior and posterior divisions of the upper trunk, and of the accessory nerve to the suprascapular nerve, was carried out with microsutures. After the operation, the aected

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Figure 1. Shoulder abuduction 170 , deltoid M4, supraspinous and 5 infraspinous muscle M3, innervated by transferred C7 at postoperative 1 year. [Color gure can be viewed in the online issue, which is available at www.interscience.wiley.com]

Figure 3. Lattismus dorsi M3 (originally innervated by C7), innervated by C8T1 at postoperative 1 year. Arrow indicates the contraction of the lattismus dorsi. [Color gure can be viewed in the online issue, which is available at www.interscience.wiley.com]

Figure 2. Elbow exion 150 , biceps M4, innervated by transferred C7, at postoperative 1 year. [Color gure can be viewed in the online issue, which is available at www.interscience.wiley.com]

Figure 4. Extensor muscles of elbow, wrist, and ngers M4 (originally innervated by C7), innervated by C8T1 at postoperative 1 year. [Color gure can be viewed in the online issue, which is available at www.interscience.wiley.com]

extremity was immobilized with a head-arm brace. On the second day after the operation, a grade 1 decrease of muscle power in the latissmus dorsi and triceps was found, but the strength of the extensor digitorum communis was normal. The area of loss of pricking pain was similar to that from preoperation, except for a reduction of pricking pain in the thumb web. At 1 week after the operation, an EMG study revealed no spontaneous electrical activity in the latissmus dorsi, triceps, and extensor digitorum communis. But the recruitment response was feeble, varying from single pattern to singlemixed pattern. At postoperative 8 months, the patient showed a shoulder abduction of 70 and external rotation of 10. The strength of the deltoid, supraspinous, and infraspinous muscles was M2, that of the elbow

exors was M3, and that of the triceps and extensor digitorum communis was M5. One year after the operation, shoulder abduction recovered to 170 and external rotation to 30, and the strength of the elbow exors to M4. The recovery of daily activity was satisfactory (Figs. 14).

DISCUSSION Clinical Signicance of Transfer of Ipsilateral C7 Root

The injury of the upper trunk alone of the brachial plexus is a common lesion in clinical practice, and ac-

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counts for one third of all brachial plexus injuries. Its main symptoms are impairment of shoulder abduction, external rotation, and elbow flexion. Since no functional disturbance occurred in patients with isolated C7 lesions,1 the major clinical presentation of injury of C57 was similar to that of C5 and C6. For treatment of C5 and C6 nerve root avulsion, our option of donor nerves for transfer included the phrenic nerve, accessory nerve, intercostal nerves, and partial fascicles of the ulnar nerve (Oberlins procedure). C5 and C6 nerve root avulsion is sometimes accompanied with injury of the phrenic nerve and accessory nerve, leading to even more insuciency of the donor nerves. We therefore used the ipsilateral C7 nerve root as donor nerve for repair of the upper trunk of the brachial plexus. Not only was the treatment outcome enhanced, but a satisfactory neurotizer for injuries of the upper trunk or even lower trunk of the brachial plexus was provided. The procedure caused no electromyography, neurophysiology, or functional disturbance except for a temporary drop of muscle strength in C7 innervated muscles.7,8 Therefore, it is safe and ecacious.

suggest the severity of injury in the former 2, to whom the accessory and phrenic nerves were simultaneously injured, which might ultimately inuence the regeneration potential and quality of spinal cord neurons, thus weakening C7 nerve root regeneration. It also conrms that the function of the suprascapular nerve is of paramount importance in maintaining shoulder function, and therefore it must be neurotized in treatment of C5 and C6 nerve root avulsion of the plexus. We conclude from this study as follows: 1) Transfer of the ipsilateral C7 nerve root is the treatment of choice for C5 and C6 nerve root avulsion of the brachial plexus in combination with phrenic nerve injury. 2) The procedure can also be performed with normal phrenic nerves with insufficiency of cardiorespiratory function. 3) In cases of C5 and C6 nerve root avulsion of the brachial plexus combined with incomplete middle and lower trunk injuries, the procedure should be used cautiously.

REFERENCES
1. Gu Y-D, Zhang G-M, Chen D-S, Yan J-G, Cheng X-M, Chen L. Seventh cervical nerve root transfer from the contralateral healthy side for treatment of brachial plexus root avulsion. J Hand Surg [Br] 1992;17:518521. 2. Gu Y-D, Chen D-S, Zhang G-M, Cheng X-U, Xu J-G, Zhang L-Y, Cai P-Q, Chen L. Long-term functional results of contra3 lateral C7 transfer. J Reconstr Microsurg 1998;14:57 59. 3. Liu J, Pho RWH, Kow AK. Neurologic decit and recovery in brachial plexus injury. J Reconstr Microsurg 1997;13:237242. 4. Teizis JK, Skoulis T, Jiginni V. Contralateral C7: a powerful 4 source of motor neurons. In: Abstract Book of the 14th Congress of the International Microsurgery Society. Corfu, Greece. 1998. 5. Gu Y-D. Symposium on brachial plexus injury: progress in contralateral C7 transfer for management of brachial plexus injuries. Hong Kong J Orthop Surg 1999;3:9698. 6. Xu J-G, Hu S-N, Wang H, Shen L-Y, Gu Y-D. A study of the clinical application of ipsilateral selective C7 transfer. Chin J Hand Surg 1999;15:3:151153. 7. Xu F, Cai P-Q, Gu Y-D, Chen D-S. Inuence of ipsilateral nerve root transfer on its innervating muscles: a preliminary report. J Chin Hand Surg 2001;17:3:133135. 8. Gu Y-D, Shen L-Y. Electrophysiological changes after severance of the C7 nerve root. J Hand Surg [Br] 1994;19:6971.

Analysis of Treatment Outcome of Transfer of Ipsilateral C7 Root

The first 2 cases suffered from C5 and C6 nerve root avulsion, as well as injuries of the phrenic nerve and accessory nerve. After transfer of the ipsilateral C7 nerve root to the upper trunk, follow-up results showed muscle strength of the elbow flexors improving to M4, but recovery of shoulder abduction and external rotation was limited. Transfer of the ipsilateral C7 nerve root to the anterior and posterior division, and of the accessory nerve to the suprascapular nerve, was performed in the latter 2 cases on account of the normal accessory nerve function. One year after the operation, striking treatment ecacy was achieved, with notable restoration of shoulder abduction and external rotation in these 2 cases. The dierence in recovering shoulder abduction between the former and the latter 2 cases may