Functional outcome of nerve transfers for traumatic global brachial plexus avulsion

Injury, Int. J. Care Injured 44 (2013) 655–660

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Functional outcome of nerve transfers for traumatic global brachial plexus avulsion Yuzhou Liu a,b,c, Jie Lao a,b,c,*, Kaiming Gao d, Yudong Gu d, Xin Zhao d a

Department of Hand Surgery, Huashan Hospital, Fudan University, 12 Wulumuqi Road, Shanghai 200040, People’s Republic of China Key Laboratory of Hand Reconstruction, Ministry of Health, 12 Wulumuqi Road, Shanghai 200040, People’s Republic of China c Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, 12 Wulumuqi Road, Shanghai 200040, People’s Republic of China d Department of Hand Surgery, Shanghai Huashan Hospital, 12 Wulumuqi Road, Shanghai 200040, People’s Republic of China b

A R T I C L E I N F O

A B S T R A C T

Article history: Accepted 8 February 2012

Background: The treatment of global brachial plexus avulsion is a demanding field of hand and upper extremity surgery. The recent development of functional and quality-of-life (QOL) assessment tools has improved quantifying these functional outcomes after surgery. Objective: We sought to combine Medical Research Council (MRC) grading with the Disability of the Arm, Shoulder, and Hand (DASH) questionnaires and Numerical Rating Scale (NRS) for pain to evaluate the functional outcome of patients who suffered complete brachial plexus avulsion before and after nerve transfers. Methods: The author carried out a retrospective review of 37 patients with global avulsion of the brachial plexus between 2000 and 2007. All of them underwent nerve transfers in Hua Shan Hospital in Shanghai. They were followed up for over 3 years for physical examination and responding to the questionnaires of DASH, NRS, as well as the satisfaction with the surgery. Results: The mean time to surgery was less than 6 months and the mean follow-up period was 4.59 years (range: 3–9 years). The effective motor recovery rate was 54%, 86%, 46% and 43%, respectively, in supraspinatus, biceps, triceps and finger flexor. Patients who underwent nerve transfers scored consistently better on the DASH score and NRS score than those before surgery. There was also a significant correlation between the change in NRS scores and patient satisfaction. Conclusion: This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients’ self-assessments. Neurolysis after neurotisations correlated positively with functional outcomes. ß 2012 Elsevier Ltd. All rights reserved.

Keywords: Brachial plexus Nerve transfer Neurolysis Functional outcome

Adult traumatic brachial plexus injuries can have devastating effects on the upper extremity function.1 Apart from motor and sensory loss, pain could aggravate and functional limitations would increase after brachial plexus injuries.2–5 The prevalence of brachial plexus injuries in the multiple trauma population is about 1.2%.6 Surgical management consists of nerve repair and nerve grafting for extraforaminal nerve root or trunk injury, and of neurotisation or nerve transfer for nerve roots avulsion.7 Nerve transfer employs redirection of an intact motor nerve from one muscle to the distal undamaged portion of a nerve from another, effectively bypassing the injured segment of nerve.1 Nowadays, patients who have surgery for brachial plexus injuries are focussed on the recovery of motor and sensory.8–11 However, the success of

* Corresponding author at: Department of Hand Surgery, Shanghai Huashan Hospital, 12 Wulumuqi Road, Jing An District, Shanghai 200040, People’s Republic of China. Tel.: +86 13817937417. E-mail address: [email protected] (J. Lao). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2012.02.006

microsurgical reconstruction should incorporate the patients’ selfassessments of their functional recovery.12 The present study was to evaluate the functional outcome of patients who suffered global brachial plexus avulsion before and after nerve transfers by Medical Research Council (MRC) grading, the Disability of the Arm, Shoulder, and Hand (DASH) questionnaires and Numerical Rating Scale (NRS) for pain. Patients were also sent an additional question regarding their satisfaction with the surgery.12

Patients and methods A retrospective review of 37 patients with global avulsion of the brachial plexus was carried out (Table 1). The inclusion criteria included global brachial plexus root avulsion, a minimum postoperative interval of over 3 years, treated by nerve transfers from 2000 to 2007 at the Department of Hand Surgery in Hua Shan Hospital in Shanghai.

656

Table 1 Patient demographics. Patient no.

Age (injury)/sex

Delay to OR (months)

Follow-up (years)

Other nerve injury

Operation

Neurolysis

DASH (pre/postoperative)

NRS (pre/postoperative)

1

29/M

<6

8

Pr–Mc,C7–Mcf, Ic–Td.Ax

No

77.5/79.2

10/5

2 3 4 5

29/M 38/M 25/M 13/M

<6 <6 <6 <6

3 4 4 5

Sa–Ss, Pr–UT, C7–LT, Ic–Td,Tr Sa–Ss,C7–Mc.Md, Ic–Td,Tr Sa–Ss,Pr–UT,C7–Ra, Ic–Td C7–Tr.Md,Ic–Mc

No No No No

44.2/27.5 60/46.7 29.2/29.2 44/14.7

6/3 5/4 8/4 9/2

6

34/M

<6

4

Sa–Ss,C7–Ra.Md, Ic–Td,Mc

Median nerve

7 8 9

19/M 19/M 16/M

<6 <6 <6

4 4 9

Sa–Ss,C7–Ra, Ic–Td,Tr Sa–Ss,Pr–Raf, C7–Md.Mc,Ic–Ax.Tr.Td Lt–Ss,C7–Md, Ic–Ax.Mc

No No No

75.8/60.8 13.3/7.5 70/16.7

10 11

37/M 30/M

>6 <6

6 5

Sa–Ss,Pr–Mc, C7–Ra.Ax,Ic–Td,Md Sa–Ss,C7–Md, Ic–Td,Mc

No No

15/10

12

15/M

<6

3

Spinal accessory nerve (complete) None Phrenic nerve (partial) None Spinal accessory nerve (partial) Phrenic nerve (complete) Spinal accessory nerve (partial) Phrenic nerve (complete) None None Spinal accessory nerve (partial) Phrenic nerve (complete) None Spinal accessory nerve (partial) Phrenic nerve (complete) None

Sa–Ss,Pr–Mc, C7–Ra,Ic–Td,Md

78.3/73.3

0/0

13 14 15 16 17 18 19 20 21 22 23

38/M 25/M 20/M 32/M 20/M 19/M 25/M 24/M 18/M 27/M 16/M

<6 <6 <6 <6 <6 <6 <6 <6 <6 <6 <6

3 5 5 3 8 3 7 5 4 4 3

Phrenic nerve (complete) Phrenic nerve (partial) None Phrenic nerve (complete) None None None None None None None

Sa–Ss,C7–Mc.Md, Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md Sa–Mcf–Ax,Pr–Mc, C7–Md,Ic–Td,Tr Sa–Ss,C7–Md, Ic–Td,Mc Sa–Ss,Pr–Mc, C7–Md.Ra,Ic–Td Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md, Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr

Median nerve Radial nerve No Median nerve Median nerve No No Median nerve No No

65/69.2 68.8/51.7 28.3/17.5

40.8/20.8 52.5/30.6 60.8/17.2

0/0 8/6 0/0 8/6 7/3 10/0 8/2 0/1 7/2 2/5 7/3

24 25 26 27 28

27/M 21/M 28/M 38/M 21/M

<6 <6 <6 <6 <6

4 5 3 9 4

Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr Sa–Ss,Pr–UT, C7–Md,Ic–Td,Tr Sa–Ss,Pr–Mc, C7–Md,Ic–Td Sa–Ss,C7–Md.Tr, Ic–Td.Mc

50/44.8 45.9/37.9 77.5/73.3 51.9/40.7

1/2 0/5 9/3 7/7 6/3

29

17/M

<6

4

None None None None Phrenic nerve (complete) None

No

23.3/52.5

1/1

30

17/M

<6

4

None

No

63.3/21.7

0/2

31

21/M

<6

4

None

No

56.7/41.7

7/4

32

20/M

<6

4

No

18.3/15.8

0/1

33

24/M

<6

4

Spinal accessory nerve (complete) Phrenic nerve (complete) None

No

20.8/16.7

2/2

34

59/M

<6

4

None

No

35.8/47.5

2/2

Pr–Mc, Sa–Ss C7–Md,Ic–Td,Tr Pr–Mc, Sa–Ss C7–Md,Ic–Td,Tr

8/7 0/5 1/7

0/0 8/5

20/18.8 86.7/23.3

Y. Liu et al. / Injury, Int. J. Care Injured 44 (2013) 655–660

Pr–Mc, Sa–Ss C7–Md,Ic–Td,Tr Pr–Mc, Sa–Ss C7–Md,Ic–Td,Tr Pr–Mc, Sa–Ss C7–Md,Ic–Td,Tr C7–Md, Mc, Ss Ic–Td,Tr

Median nerve Median nerve Radial nerve No No Median nerve No No

5/5

Pr–Mc, Sa–Ss No 43.3/46.7 3/1 C7–Md,Ic–Td,Tr 36 26/M <6 4 None Pr–Mc, Sa–Ss No 9.2/20.8 0/2 C7–Md,Ic–Td,Tr Sa–Ss Median nerve 30/31.7 4/1 37 20/M <6 4 Phrenic nerve (complete) C7–Md, Ic–Mc,Ra Md: median nerve; Ax: axillary nerve; Ra: radial nerve; Mcf: medial cutaneous nerve of forearm; LT: lower trunk; Ss: suprascapular nerve; Pr: phrenic nerve; Raf: branch of radial nerve forearm; Sa: spinal accessory nerve; Tr: triceps branch of radial nerve; Ic: intercostal nerve; Td: thoracodorsal nerve; C7: 7th cervical nerve root from the contralateral side; Lt: lateral thoracic nerve from the contralateral side; UT: lateral branch of upper trunk; Mc: musculocutaneous nerve.

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The exclusion criteria included diabetes, Volkmann contracture, fracture on the affected limb, rib fracture on the affected side and brain trauma. All of the 37 patients were confirmed to have global brachial plexus root avulsion by preoperative and intra-operative electromyography, physical examination and especially by intra-operative exploration. Patients were treated on a case-by-case basis depending on which functional nerves were available for nerve transfer procedures (Table 2). After operation, they were advised to do rehabilitation exercises, carry out electrical stimulation therapy (Fig. 1) and take neurotrophic drugs. Rehabilitation exercises and electrical stimulation therapy were designed according to way of neurotisation. Evaluation Patients came to our department for physical examination and responded to the questionnaires of DASH, NRS as well as the satisfaction with the surgery. The British MRC grading system was used for motor assessment. The DASH outcome measure is a 30-item, self-report questionnaire designed to measure physical function and symptoms in people with any of several musculoskeletal disorders of the upper limb.13 It does not matter which hand or arm you use to perform the activity. Each question in the DASH is scored on a scale from 1 to 5, with a maximum total score of 100 and a minimum of 0; lower scores indicate better results.12 NRS14 is usually based on a scale from 0 to 10 and this scale assigns a measurable number to your pain level. Zero represents no pain at all while 10 represents the worst imaginable pain. Statistical analysis The raw DASH results were converted to normative scores. The total DASH score = [(sum of n responses) 1]  25/n, which was the normative scores. The DASH and NRS scores before operations were compared with those at least 3 years after operation. Comparisons were analysed using t-test for parametric data and Wilcoxon signed rank sum test for non-parametric data. P values were two-tailed, and P values less than 0.05 were considered significant. All analyses were performed using Statistical Package for the Social Sciences (SPSS) version 13.0 software.

None 4 29/M 35

<6

Age (injury)/sex Patient no.

Table 1 (Continued )

Delay to OR (months)

Follow-up (years)

Other nerve injury

Operation

Neurolysis

DASH (pre/postoperative)

NRS (pre/postoperative)

Y. Liu et al. / Injury, Int. J. Care Injured 44 (2013) 655–660

Results The 37 patients were all males with a mean age of 25.29 years (range: 13–59) at the time of injury (Table 1). Motor vehicle and motorcycle accidents accounted for injuries in 29 patients. Other road accidents included a bicycle and two pedestrian accidents. Two patients had traction injury of upper limb and two patients suffered weight dropping on the shoulder. Explosion led to a patient’ brachial plexus avulsion. The time from injury to surgery was all less than 6 months except for one patient, who was dissatisfied with the surgery. The mean follow-up period from surgery to when the questionnaires were finished was 4.59 years (range: 3–9 years). Sixteen patients had transfer of spinal accessory nerve–suprascapular nerve, phrenic nerve–lateral branch of upper trunk, seventh cervical nerve root from the contralateral side– median nerve, intercostal nerves–triceps branch of radial nerve and thoracodorsal nerve (Table 2). This proposal of nerve repair was commonly used in brachial plexus injuries. Nine patients had proceeded neurolysis. All patients finished physical examination, the NRS questionnaires and responded to the satisfaction with the surgery. Six patients among them did not complete the DASH questionnaires.

Y. Liu et al. / Injury, Int. J. Care Injured 44 (2013) 655–660

658 Table 2 Donor nerves and recipient nerves in neurotisation.

Table 3 Muscle power after operation.

Donor nerves

Recipient nerves

Muscle power

M0

M1

M2

M3

M4

Efficiency

Phrenic nerve

Lateral branch of upper trunk Musculocutaneous nerve Branch of radial nerve forearm Axillary nerve (graft: medial cutaneous nerve of forearm)

Supraspinatus Biceps Triceps Finger flexor

4 1 11 8

3 2 6 7

10 2 3 6

12 12 11 14

8 20 6 2

54% 86% 46% 43%

Spinal accessory nerve

Suprascapular nerve

Intercostal nerves

Triceps branch of radial nerve Thoracodorsal nerve Median nerve Musculocutaneous nerve Axillary nerve

7th cervical nerve root from the contralateral side

Median nerve Musculocutaneous nerve Radial nerve Axillary nerve Medial cutaneous nerve of forearm Lower trunk

Lateral thoracic nerve from the contralateral side

Suprascapular nerve

MRC grading All of the muscle strength was M0 in the affected limb with brachial plexus avulsion preoperatively. There were 20 patients (54%) who got the recovery of M4 strength of biceps muscle, 12 patients (32%) recovered to M3, while M2 or less power was obtained in five patients (14%) after surgery. Return of muscle

power of M3 or better is regarded as effective. The effective recovery results were 86% in musculocutaneous nerve. Supraspinatus muscle recovered to M3 or more in 20 patients, M2 in 10 patients, M1 in three patients and M0 in four patients. The effective motor recovery rate was 54%. Triceps muscle recovered to M3 or more in 17 patients, M2 in three patients, M1 in six patients and M0 in 11 patients. The effective motor recovery rate was 46%. Finger flexors recovered to M3 or more in 16 patients, M2 in six patients, M1 in seven patients and M0 in eight patients. The effective motor recovery rate was 43% (Table 3). Scoring DASH and NRS questionnaires The DASH score normalised mean for the study group before surgery was 47.9 (standard deviation, 22.8). Compared with that after operation, normalised mean of 35.7 (standard deviation, 20.4) showed more disability before surgery in the brachial plexus injury group (P = 0.002). The mean of NRS score before surgery was 4.3 (standard deviation, 3.6) while years after surgery it was 3.0 (standard deviation, 2.2), which was significantly better than that before surgery (P = 0.027). The DASH score of seven patients after

Fig. 1. Electrical stimulation therapy. (a) Intercostal nerves–triceps branch of radial nerve; (b) spinal accessory nerve–suprascapular nerve; (c) 7th cervical nerve root from the contralateral side–ulnar nerve–median nerve; (d) phrenic nerve–lateral branch of upper trunk; (e) electrical stimulator.

Y. Liu et al. / Injury, Int. J. Care Injured 44 (2013) 655–660

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Table 4 The DASH and NRS score of preoperative and postoperative patients. Instrument scale

Mean  SD (pre)

Mean  SD (pro)

Mean  SD (differences)

P value

DASH (n = 31) NRS (n = 37)

47.9  22.8 4.3  3.6

35.7  20.4 3.0  2.2

12.2  20.1 1.3  3.4

0.002 0.027

Table 5 Correlation of the satisfaction of surgery with LDASH and LNRS. Instrument scale

Spearman’s P correlation coefficient (P-value)

LDASH n = 31 LNRS n = 37

0.058 (0.756) 0.363 (0.027)

nine patients had neurolysis of median nerve or radial nerve of forearm. Statistical analysis of change of the NRS score showed no significant difference and did not suggest any trend between patients with or without neurolysis, but change of the DASH score in patients with neurolysis was significantly larger than that without neurolysis (P = 0.022) (Table 6).

LDASH: DASH score (preoperative) DASH score (postoperative); LNRS: NRS score (preoperative) NRS score (postoperative).

operation were larger than that before operation, which suggested these seven patients might be more disabled after operation (Table 4). Satisfaction with surgery The satisfaction with surgery was shown by the following question: ‘‘If you were to go back in time, would you choose to have the brachial plexus surgery again?’’ with the following possible responses: (a) definitely yes, (b) probably yes, (c) uncertain and (d) definitely not.12 Twenty-three patients (62%) answered ‘definitely yes’ or ‘probably yes’ in response to the question on their readiness to undergo surgery again. Three patients answered ‘definitely not’, and eleven were ‘uncertain’. There was a significant correlation between satisfaction with surgery and the change in NRS scores using the Spearman’s rho correlation analysis (Table 5). Phrenic nerve and spinal accessory nerve injury Isolated spinal accessory nerve injury and isolated phrenic nerve injury occurred in one and six patients, respectively. Five patients had both phrenic nerve and spinal accessory nerve injuries. Statistical analysis showed: the change of the DASH and NRS score before and after operation in patients who had phrenic nerve or spinal accessory nerve injury was not significantly different with that in the other patients. P = 0.976(LDASH) and P = 0.656(LNRS) (Table 6). Neurolysis According to motor performance, the time after the neurotisation and Tinel’s sign combining with electromyography (EMG),

Complications Thirty-one patients (84%) sustained varying degrees of diaphragmatic paralysis and elevation (for 1–1.5 intercostal spaces) on the surgically treated side as seen on chest X-ray films. No patient experienced pulmonary problems following the surgery. Twenty-one patients (57%) experienced paresthesia on the thumb, index and middle pulp of the donor hand within half a year after surgery and the sensory deficit completely recovered spontaneously in all patients now. One patient (3%) had wound infection within 3 weeks after surgery, but now the wound healed (Table 7). Discussion Evaluating outcomes of neurotisation for global brachial plexus avulsions is extremely complex.15 Choi et al.16 used overall life satisfaction, employment status and the impact of the brachial plexus injury on life domains to evaluate long-term subjective outcome following surgical treatment for brachial plexus injury. But his study lacked specialised and validated assessment tools for measuring upper limb function. Ahmed-Labib et al.12 introduced the use of validated assessment tools (DASH, short form 36 (SF-36), pain visual analog scale (PVAS) in quantifying subjective functional outcome, which were compared with those of the general population, but his study lacked DASH scores preoperatively and no comparison before and after surgery. This retrospective self-control study evaluated the functional outcome of 37 patients with global brachial plexus avulsions before and after nerve transfers according to MRC grading, DASH and NRS assessment tools combining with satisfaction with surgery. When we evaluated the function of the whole upper limb, it was possible to demonstrate the value of neurosurgical repair in lesions of the brachial plexus.15 As expected, muscle power of the upper limb in the patients with global brachial plexus avulsions recovered to varying grading after surgery (Table 3) and

Table 6 Pr/Sa injury and functional outcome, neurolysis and functional outcome. Instrument scale

With Pr or Sa injury

Without Pr or Sa injury

P value (Pr or Sa)

With neurolysis

Without neurolysis

P value (neurolysis)

LDASH (mean  SD) LNRS (mean  SD)

12.0  19.1 1.7  3.3

12.2  20.9 1.1  3.5

0.976 0.656

24.8  21.1 2.3  3.8

7.0  17.6 1.0  3.3

0.022 0.303

Pr: phrenic nerve; Sa: spinal accessory nerve; LDASH: DASH score (preoperative)

DASH score (postoperative); LNRS: NRS score (preoperative)

NRS score (postoperative).

Table 7 Complications. Complications

Diaphragmatic paralysis and elevation on one side

Breathing problems

Paresthesia on the contralateral hand within half a year after surgery

Paresthesia on the contralateral hand now

Infection within 3 weeks

Infection now

Num Rate

31 84%

0 0

21 57%

0 0

1 3%

0 0

660

Y. Liu et al. / Injury, Int. J. Care Injured 44 (2013) 655–660

the scores of DASH and NRS after operation were significantly better than those preoperatively. This means these nerve transfers had a positive effect on prognosis of global brachial plexus avulsions. There was also a significant correlation between the change in NRS scores and patient satisfaction (Table 5). Although patient satisfaction was subjective, the correlation demonstrated the usefulness of these questionnaires. The outcome of nerve repair and nerve reconstruction after nerve injuries is influenced by many factors, such as age, the timing of nerve repair, type of lesion, level of injury and other components of importance for functional recovery.17 In this study, there was a 59-year-old male. His muscle power recovered to M3, M2, M0 and M0, respectively, in supraspinatus, biceps, triceps and finger flexor, and the DASH score after operation was larger than that preoperatively, which suggested functional outcome had negative correlation with age. Only one patient underwent surgery more than 6 months (9 months) after injury. His muscle power recovered to M2, M0, M3 and M0, respectively, in supraspinatus, biceps, triceps and finger flexor, and he was dissatisfied with the functional outcome according to the satisfaction questionnaire. There was no significant correlation between phrenic nerve or spinal accessory nerve injury and subjective functional outcomes, which could be explained that although patients who suffered phrenic nerve or spinal accessory nerve injury had less donor nerves than the other patients, other neurotisations such as intercostal nerve transfer or C7 from the contralateral side transfer were useful for functional recovery instead of the abovementioned nerve transfer. Kanaya et al.18 reported that neurolysis performed before 6 months contributed to functional recovery after brachial plexus injury (BPI). This study also suggested the effectiveness of neurolysis after neurotisations for functional recovery according to change of the DASH score, but neurolysis did not have correlation with change of the NRS score. In the study, the nerve transfer of phrenic nerve – lateral branch of upper trunk led to diaphragm paralysis and elevation on one side, but didn’t result in breathing disorder because of contralateral lung function compensatory. Xu19 reported that in young patients with healthy lung function, unilateral phrenic nerve transection surgery can cause unilateral diaphragmatic paralysis and reduce the inspiration muscle force; however, most pulmonary function parameters gradually recover to preoperative levels within 1 year. The paresthesia on the thumb, index and middle pulp of the donor hand appeared on some patients for half a year, which could have resulted from the contralateral C7 transfer. But the sensory deficit completely recovered spontaneously after a year. This was consistent with Gao’s20 report that all patients had temporary sensory abnormality after surgery, but the sensory deficit had completely recovered spontaneously in all patients at the last office visit. Due to lack of the DASH score data for Chinese general population, the outcomes measured were not compared with those of the general population. Selection bias related to surgeon preference, technical difficulty and number of donor nerves may have influenced the type of surgical method selected.15 Due to the homogeneous preoperative patient population, the selection bias was minimal. The study also had the deficiencies inherent in all retrospective reviews. The research relied on memory recall and the scores may have changed due to patients’ memories,

expectations and willingness to assist the study as well as patient adaptations to their disability which alone would improve their scores. MRC grading was used to assess each muscle and it was difficult to be correlated with DASH and NRS scores, which evaluated outcome in its entirety. But we will do more literature search and try to explore and study the correlation between them for functional outcome of nerve transfers for traumatic global brachial plexus avulsion. Conclusion This study validated the effect of the nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients’ self-assessments. Neurolysis after neurotisations correlated positively with functional outcomes. Conflict of interest All authors hereby declare that they have no conflicts of interest to disclose. Acknowledgements We thank Li Jiali for assistance with the data collection and this study was supported by the Hand Surgery Department in Huashan Hospital and Hand Function Research Center in Fudan University. References 1. Rohde RS, Wolfe SW. Nerve transfers for adult traumatic brachial plexus palsy. HSSJ 2007;3:77–82. 2. Bruxelle J, Travers V, Thiebaut JB. Occurrence and treatment of pain after brachial plexus injury. Clin Orthop Relat Res 1988;237:87–95. 3. Leffert RD, Seddon H. Infraclavicular brachial plexus injuries. J Bone Joint Surg Br 1965;47:9–22. 4. Ochiai N, Nagano A, Sugioka H, Hara T. Nerve grafting in brachial plexus injuries. Results of free grafts in 90 patients. J Bone Joint Surg Br 1996;78:754–8. 5. Sedel L. The management of supraclavicular lesions. Clin Plast Surg 1984;11: 121–6. 6. Midha R. Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery 1997;40:1182–9. 7. Songcharoen P. Management of brachial plexus injury in adults. Scand J Surg 2008;97:317–23. 8. Dubuisson AS, Kline DG. Brachial plexus injury: a survey of 100 consecutive cases from a single service. Neurosurgery 2002;51:673–83. 9. Kline DG. Perspectives concerning brachial plexus injury and repair. Neurosurg Clin N Am 1991;2:151–64. 10. Kandenwein JA, Kretschmer T, Engelhardt M, Richter HP, Antoniadis G. Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases. J Neurosurg 2005;103:614–21. 11. Kline DG, Tiel RL. Direct plexus repair by grafts supplemented by nerve transfers. Hand Clin 2005;21. 55–69, vi. 12. Ahmed-Labib M, Golan JD, Jacques L. Functional outcome of brachial plexus reconstruction after trauma. Neurosurgery 2007;61:1016–23. 13. About the DASH. http://www.dash.iwh.on.ca/about.htm [accessed 25.02.06]. 14. Flaherty E. How to try this: using pain-rating scales with older adults. Am J Nurs 2008;108:40–7. 15. Ricardo M. Surgical treatment of brachial plexus injuries in adults. Int Orthop (SICOT) 2005;29:351–4. 16. Choi PD, Novak CB, Mackinnon SE, Kline DG. Quality of life and functional outcome following brachial plexus injury. J Hand Surg [Am] 1997;22:605–12. 17. Dahlin LB. Techniques of peripheral nerve repair. Scand J Surg 2008;97:310–6. 18. Kanaya F, Gonzalez M, Park CM. Improvement in motor function after brachial plexus surgery. J Hand Surg Am 1990;15:30–5. 19. Xu WD, Gu YD, Lu JB, Yu C, Zhang CG, Xu JG. Pulmonary function after complete unilateral phrenic nerve transection. J Neurosurg 2005;103(3):464–7. 20. Kaiming G, Jie L, Xin Z, Yudong G. Outcome of partial contralateral C7 nerve transfer—results of 46 patients. Neurosurgery 2011. July 25 [Epub ahead of print].