Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 45:
Direct Surgery of Traumatic Lesions of the Brachial Plexus
  Intradural avulsions can involve one, several or even all roots of the brachial plexus. Neurotization aims to salvage the functional or trophic condition of the upper limb. The principle of neurotization dates from the turn of the century. Harris and Low were the first to propose it in 1903,1 followed by Tuttle, who, in 1913, suggested the use of the spinal accessory nerve.2 Vulpius and Stoeffel suggested the use of the N. pectoralis.42 In 1929, Foerster used the thoracicus longus nerve.43 Yeoman, Seddon, and Fantis did neurotization with the intercostal nerves in 1948,44,45 and the concept was taken up again by Tsuyama in Japan in 1972.46 In 1980, Brunelli proposed to use the whole cervical plexus.47 As for us, we followed Kotani and Allieu and used the spinal accessory nerve, which comprises about 1,700 fibers to reinnervate the biceps muscle.48,49 The spinal accessory nerve is used at its exit point from the sternocleidomastoid muscle; a 5 to 10 cm long graft connects it to the fascicular group of the musculocutaneous nerve, which has usually been dissected interneurally on a length of 4 cm in the lateral cord.

Out of seven neurotizations of the biceps muscle, we obtained three good or very good results, one average, and three poor or null results. Narakas, by pooling all spinohumeral neurotizations done by seven surgical teams, has shown that 37% of the cases had useful results as far as the biceps was concerned. 50,51


We continue to neurotize the biceps using this technique; it is advantageous because functional results are acceptable in nearly 40% of the cases and because the inferior portion of the trapezius muscle is preserved, being innervated in most cases by rami from the cervical plexus as demonstrated by Bonnel.36

At present, however, there is an alternate possibility to the use of biceps neurotization, i.e., neurotization by intercostal nerves. The idea of Seddon was recently taken up again by Tsuyama.34,46 Three or four intercostal nerves are used. Respiratory potentialis sent into the biceps muscle can restore true function to the elbow after a period of time. The fatigue phenomenon sets in relatively quickly, but there is some adaptation in the long run: respirator potentials fade away and are replaced by voluntary muscle activity. This method is presently pursued in Japan, where it was developed systematically by the team of Tsuyama.46 In Europe it is used on an equal footing with neurotization by the spinal accessory nerve and complementary neurotization by the cervical plexus as developed more recently by Brunelli.23,47 Narakas prefers to use the spinal accessory nerve to neurotize the suprascapularis muscle, and to neurotize the biceps muscle by intercostal nerve transfer.50

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