In this study we performed nerve transfers for varieties of lesions proving that this technique is valuable option for management of peripheral nerves injuries.
We used nerve transfer technique for patients with no available proximal nerve stump as in C5 & C6 root avulsion or when patient presented late at 6 months or later to save time and to reach the motor end plates earlier before irreversible muscle fibers damage as in double transfer using fascicles from the ulnar and median nerves to restore elbow flexion.
Also we used this technique as augmentation for proximal nerve repair as in high ulnar nerve palsy, we transferred AIN branch to pronator quadratus end to side to deep branch of ulnar nerve for neurotization of intrinsic muscles of the hand. Also, we used as alternative to tendon transfer for patient with radial nerve palsy to restore both wrist and fingers extension.
We managed to achieve functional recoveries compared to series in literatures and we noticed that the most determinant factor is time before surgery.
The limitations of this study are doing transfers for different diagnoses making numbers available for statistical analysis relatively low and comparison to similar studies not valuable.
We did not use CT myelography or MRI as routine for patients with brachial plexus palsy. However, they are valuable investigations as they help in making decisions like timing of exploration (as early as possible when there is evidence of avulsion), or whether to explore or not (as in patient with C5 & C6 avulsion), and they save time during exploration
We did not use EMG or NCS as routine for all patients as some of them presented late at 6 months or later without baseline EMG after the injury. However, we see that doing baseline EMG 4 to 6 weeks after the injury and another one for follow up after 12 weeks is essential to detect electrophysiological recovery.
We believe that patients continue to improve for 2 to 3 years after nerve surgery and aggressive rehabilitation. The average follow up period was 14.79 months and we need more time for better evaluation and finalizing the results.
Our recommendation:
- for patients with traumatic brachial plexus palsy C5 & C6 avulsion detected by CT myelography or MRI is to do double transfer for shoulder ( spinal accessory to suprascapular and radial to axillary transfer ) and double transfer for elbow flexion ( ulnar to biceps and median to brachialis).
- In patients C5& C6 without evidence of avulsion on CT myelography or MRI, we recommend doing baseline EMG at 4 weeks to be repeated again after 12 weeks to detect early electrophysiological recovery. If no improvement (clinically or electrophysiologically) we do exploration and assessment of the lesion extent and the length of the nerve graft needed and we augment the repair with nerve transfer tailored for each case as required.
- In patient with high ulnar nerve palsy we recommend to augment the nerve repair with end to side transfer of AIN to pronator quadratus to deep branch of ulnar nerve.
- We recommend to operate as early as possible within 6 months maximum at 9 months for maximum benefits to be achieved.
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