Edmonton, Alberta, Canada From the Divisions of Plastic and Reconstructive Surgery and Physical Medicine and Rehabilitation, University of Alberta.
Plast Reconstr Surg. 2013 Dec;132(6):985e-992e. doi: 10.1097/PRS.0b013e3182a97e13.
Current surgical management of obstetrical brachial plexus injury is primary reconstruction with sural nerve grafts. Recently, the nerve-to-nerve transfer technique has been used to treat brachial plexus injury in adults, affording the benefit of distal coaptations that minimize regenerative distance. The purpose of this study was to test the hypothesis that nerve transfers are effective in reconstructing isolated upper trunk obstetrical brachial plexus injuries.
Ten patients aged 10 to 18 months were treated with three nerve transfers: spinal accessory nerve to the suprascapular nerve for shoulder abduction and external rotation; a radial to axillary nerve for shoulder abduction; and ulnar or median nerve transfer to the musculocutaneous nerve for elbow flexion. Patients were assessed preoperatively and postoperatively using the Active Movement Scale. All patients were followed regularly for up to 2 years.
Improvement in elbow and shoulder function was observed between 6 and 24 months. By 6 months, all patients passed the cookie test. At 24 months, shoulder abduction improved from 3.7 ± 0.6 to 5.0 ± 0.5, shoulder external rotation from 1.8 ± 0.4 to 4.3 ± 0.6, shoulder flexion from 3.7 ± 0.5 to 5.4 ± 0.5, elbow flexion from 3.7 ± 0.6 to 6.3 ± 0.2, and forearm supination from 2.1 ± 0.4 to 5.9 ± 0.2. There was no clinically appreciable donor-site morbidity.
Nerve transfers reduced operative times compared with traditional nerve grafting procedures. Those patients showed significant gains in Active Movement Scale score by 24 months postoperatively, comparable to results achieved by nerve grafting. These findings support nerve transfers as a potential alternative treatment option for upper trunk obstetrical brachial plexus injuries.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
目前产科臂丛神经损伤的手术治疗方法是采用腓肠神经移植进行初次重建。最近，神经对神经转移技术已被用于治疗成人臂丛神经损伤，其优势在于可以进行远端吻合，从而最大限度地减少再生距离。本研究旨在验证神经转移术对治疗孤立性上干产科臂丛神经损伤有效的假设。
10 名年龄在 10 至 18 个月的患者接受了 3 种神经转移术治疗：副神经至肩胛上神经用于肩外展和外旋；桡神经至腋神经用于肩外展；尺神经或正中神经转移至肌皮神经用于肘部弯曲。所有患者均采用主动运动量表（Active Movement Scale）进行术前和术后评估。所有患者均进行了长达 2 年的定期随访。
术后 6 至 24 个月观察到肘部和肩部功能的改善。术后 6 个月时，所有患者均通过了饼干测试。24 个月时，肩外展从 3.7±0.6 增加到 5.0±0.5，肩外旋从 1.8±0.4 增加到 4.3±0.6，肩前屈从 3.7±0.5 增加到 5.4±0.5，肘部弯曲从 3.7±0.6 增加到 6.3±0.2，前臂旋后从 2.1±0.4 增加到 5.9±0.2。供区无明显的并发症。
与传统的神经移植手术相比，神经转移术可减少手术时间。术后 24 个月，患者的主动运动量表评分显著提高，与神经移植术的结果相当。这些发现支持神经转移术作为治疗上干产科臂丛神经损伤的一种潜在替代治疗选择。
临床问题/证据水平：治疗性，IV 级。
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