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Long Thoracic Nerve Neurotization for Restoration of Shoulder Function in C5-7 Brachial Plexus Preganglionic Injuries: Case Report
SCIENTIFIC ARTICLE
Long Thoracic Nerve Neurotization for Restoration of Shoulder Function in C5-7 Brachial Plexus Preganglionic Injuries: Case Report Tetsuya Yamada, MD, Kazuteru Doi, MD, PhD, Yasunori Hattori, MD, PhD, Shushi Hoshino, MD, Soutetsu Sakamoto, MD, Yuichiro Arakawa, MD C5-7 brachial plexus preganglionic injuries are usually associated with complete paralysis of the long thoracic nerve. This makes it difficult to provide satisfactory shoulder function by neurotizing only the suprascapular nerve, compared with C5 and C6 preganglionic injuries, in which the long thoracic nerve is spared. We present a case report of a 21-year-old man who sustained a C5-7 brachial plexus preganglionic injury and obtained excellent shoulder function by intercostal nerve transfer to the long thoracic nerve in addition to neurotization of the suprascapular nerve. Our report emphasizes the importance of restoring the activity of the long thoracic nerve. (J Hand Surg 2010;35A:1427–1431. Copyright © 2010 by the American Society for Surgery of the Hand. All rights reserved.) Key words Brachial plexus, football, long thoracic nerve, shoulder function.
REVIOUS ARTICLES IN the literature have emphasized the value of suprascapular and axillary nerve repairs for reconstruction of shoulder abduction after upper-type paralysis of brachial plexus.1– 4 However, Suzuki et al.5 pointed out the importance of the long-thoracic nerve for shoulder abduction and flexion, because the range of active shoulder abduction after spinal accessory nerve to suprascapular nerve transfer without a functioning serratus anterior muscle is significantly less than one with a working serratus anterior muscle (p ⫽ .009). The relationship and contribution of the glenohumeral and scapulothoracic joints, the so-called scapulohumeral rhythm, allows the shoulder to move through its full range of elevation. Biomechanical studies have
P
FromtheDepartmentofOrthopedicSurgery,OgoriDaiichiGeneralHospital,Ogori,Yamaguchi,Japan. Received for publication March 14, 2010; accepted in revised form May 26, 2010. TheauthorsaregratefultoDr.AbhijeetL.Wahegaonkar,MD,forassistancewitheditingthisarticle. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Tetsuya Yamada, MD, Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3, Shimogo, Ogori, Yamaguchi City, Yamaguchi Prefecture, 754-0002, Japan; e-mail: [email protected]. 0363-5023/10/35A09-0004$36.00/0 doi:10.1016/j.jhsa.2010.05.024
shown a 2:1 ratio for overall glenohumeral-scapulothoracic motion.6 The serratus anterior muscle acts not only as an important mover of the scapulothoracic joint, but also as a stabilizer of the scapula. The serratus anterior muscle is innervated by the long thoracic nerve, which originates from the C5 to C7 nerve roots. In C5, C6, and C7 brachial plexus preganglionic injuries, therefore, the serratus anterior muscle is completely paralyzed. Treatment of this type of paralysis can restore satisfactory shoulder abduction only if combined with repair of the long thoracic nerve. On the other hand, in C5 and C6 preganglionic injuries, the lower part of the serratus anterior muscle is working. This type of paralysis shows an excellent outcome of shoulder abduction with repair of only the suprascapular nerve. Long thoracic nerve repair is imperative for C5, C6, and C7 preganglionic injuries to obtain satisfactory functional outcome. We present the successful use of intercostal nerve transfer to the long thoracic nerve to restore shoulder function in a patient with C5, C6, and C7 brachial plexus preganglionic injuries. CASE REPORT A 20-year-old right-handed man sustained a left brachial plexus injury when being tackled while playing
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1427
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C5-7 BRACHIAL PLEXUS PREGANGLIONIC INJURY
FIGURE 1: Preoperative photograph showing winging of the left scapula and atrophy of the infraspinatus and deltoid muscles.
football. He was referred to our clinic for further treatment 5 weeks after injury. Preoperative findings Clinically, the patient had winging of the left scapula (Fig. 1). The deltoid, supraspinatus, infraspinatus, and biceps brachii muscles were completely paralyzed and manual muscle testing of all these muscles, according to Medical Research Council Scoring, yielded a score of M0. Complete paralysis was confirmed by needle electromyography. The pectoralis major, triceps brachii, wrist, and finger extensor muscles were scored M4. The shoulder protraction test for evaluation of the serratus anterior muscle showed 2 finger breadths, which indicated complete paralysis. The patient had hypoesthesia in the C5, C6, and C7 dermatome distribution. Tinel’s sign was absent. Computed tomographic myelography revealed absence of the C5 and C6 roots and the presence of meningocele of the C7 root (Fig. 2). Surgery for exploration and spinal accessory nerve to suprascapular nerve transfer Ten weeks after the injury, the patient underwent brachial plexus exploration. We explored the C5, C6, and C7 nerve roots through a transverse cervical skin incision. The C5 and C6 nerve roots showed a neuroma in continuity. No muscular contraction was observed by electric stimulation of the C5 and C6 nerve roots. The C7 root was completely avulsed. We did not detect intraoperative evoked spinal cord potentials in C5 and
FIGURE 2: Preoperative computed tomographic myelography showing the absence of the left C5 and C6 roots and the presence of meningocele of the left C7 root, which implies root avulsion (arrow), and intact C8 and T1 roots.
C6 roots. The long thoracic nerve coming off the C5 and C6 roots immediately adjacent to the intervertebral foramina was identified. Contraction of the serratus anterior muscle did not occur with electric stimulation of the long thoracic nerve. Preoperative computed tomographic myelography and intraoperative findings and electrophysiological examination confirmed complete preganglionic injuries of the C5, C6, and C7 nerve roots. We explored the spinal accessory nerve through a transverse incision along the clavicle. The proximal branch of the spinal accessory nerve, which innervated to the upper part of the trapezius, was preserved, whereas the terminal branch of the nerve was divided as far distally as possible and transferred to the supraclavicular region. The suprascapular nerve arising from the C5 root was identified under the omohyoid muscle. The nerve was then transected at the point of its division from the C5 root and was directly anastomosed to the spinal accessory nerve stump in the supraclavicular fossa with epineural suture. At the same time, a single posteromedial fascicle of the ulnar nerve was transferred to the common branch of the musculocutaneous nerve for reconstruction of elbow flexion.7,8 Surgery for intercostal nerve to long thoracic nerve transfer Another 10 weeks after the first surgery, we performed third and fourth intercostal nerves to long thoracic nerve
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procedure then was carried out for harvesting the fourth medial intercostal nerve. After the dissection of the third and fourth intercostal nerve, each medial intercostal nerve was transferred to the long thoracic nerve at the third intercostal space (Fig. 3).
FIGURE 3: Intraoperative photograph and schematic drawing of the left chest wall before coaptation of the intercostal nerve to the long thoracic nerve. a, The third intercostal nerve. b, the long thoracic nerve. c, the fourth intercostal nerve.
transfer. The intercostal nerves and long thoracic nerve were exposed through an incision from the axilla and along the chest wall behind the pectoralis major to the level of the nipple. We identified the long thoracic nerve that courses down posterior to the midaxillary line. The third medial intercostal nerve could be found under the periosteum of the inferior margin of the third rib. We identified this nerve by tracing the lateral sensory branch of the intercostal nerve proximally. Dissection of the medial intercostal nerve was continued enough to reach the long thoracic nerve. A similar
Postoperative course One week after the surgery, passive exercise of shoulder and elbow joints was started. We used low-frequency electrical stimulation of the denervated muscles until electromyographic reinnervation was seen. Electromyographic reinnervation of the supraspinatus and biceps brachii muscles were detected at 3 months after surgery and the serratus anterior muscle was reinnervated at 5 months after surgery. After electromyographic documentation of the denervated muscles, electromyographic biofeedback techniques9 were started to train the reinnervated muscles to move the shoulder and elbow. After the medical rehabilitation, the patient came back to the university and trained the reconstructed upper limb by himself, with his team’s trainers. Two years after the surgery, the patient had no scapular winging and has achieved 180° of active shoulder flexion, 180° of abduction, and 60° of external rotation. Active range of motion of the elbow was 0° to 140° (Fig. 4). According to the 0 to 5 grading system for shoulder muscle strength, the patient demonstrated grade M4 muscle strength for flexion, abduction, and external rotation, although quantitative analysis of muscle strength for shoulder abduction using a Kin-Com (Chat-
FIGURE 4: Photograph 2 years after the surgery. A Full arm elevation and no winged scapula. B Elbow flexion and remaining atrophy of the deltoid muscle.
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FIGURE 5: The patient is able to throw the ball with the left involved hand.
tecx, Harrison, TN) dynamometer showed 30% of the contralateral normal side. The deltoid muscle remained completely paralyzed, which was proved by needle electromyography, because the axillary nerve had not been repaired. The patient resumed playing American football at his previous level and can play games as a quarterback (Fig. 5). DISCUSSION A lot of confusion and misunderstandings exist in upper-type brachial plexus injury concerning preoperative evaluation and postoperative functional outcomes. The most critical point is that preoperative paralysis is not classified strictly according to the level of injury and number of the injured root, although Hentz and Doi10 stated that there are marked differences in outcomes between C5 and C6 and the C5, C6, and C7 preganglionic injuries. The spinal accessory nerve is the donor nerve of choice to restore shoulder function.1,5,10,11 However, limited shoulder function was obtained in previous reports of spinal accessory nerve transfer to the suprascapular nerve, especially in C5, C6, and C7 preganglionic injuries.1,2,5,10 –13 Different investigators have shown that 20° to 60° of shoulder abduction may be achieved when using spinal accessory nerve to suprascapular nerve transfer.1,2,5,10,14 These differences in functional results arose because the investigators were not aware of the level of injury and number of involved roots, and especially the function of the serratus anterior
muscle. Hentz and Doi10 emphasized that C5, C6, and C7 preganglionic injuries should be distinguished from C5 and C6 preganglionic injuries when discussing evaluation of paralysis, the plan of reconstruction, and its outcome. The mean active ranges of shoulder motion after C5, C6, and C7 preganglionic injuries by spinal accessory nerve to the suprascapular nerve transfer without long thoracic nerve repair were 50.7° in flexion and 59.3° in abduction in our previous cases.5 In this case, our patient obtained an excellent outcome by intercostal nerve to long thoracic nerve transfer in addition to spinal accessory nerve to suprascapular nerve transfer, compared with our previous patients. The long thoracic nerve originates from C5 to C7 nerve roots in normal subjects. It is the sole innervation to the serratus anterior muscle, which stabilizes the scapula and provides upward and lateral rotation of the inferior angle of the scapula.15,16 In general, overall efforts to obtain 90° of shoulder abduction require approximately a 2:1 ratio of glenohumeral motion to this scapulothoracic motion. In preganglionic injuries of C5 and C6 nerve roots, the lower part of the serratus anterior muscle is working. The remaining innervated part of the serratus anterior stabilizes and moves the scapulothoracic joint and prevents winging of the scapula. On the other hand, in preganglionic injuries of the C5, C6, and C7 nerve roots, there is no functioning part of the serratus anterior muscle. Recently, Uerpairojkit et al.3 reported good results with combined nerve transfers: spinal accessory nerve to the suprascapular nerve, the nerve to the long head of the triceps to axillary nerve, and a branch of the thoracodorsal nerve to the long thoracic nerve in shoulder reconstruction of C5 and C6 preganglionic injuries. However, the long thoracic nerve should not have been paralyzed completely in C5 and C6 nerve root injuries even if it might not have reacted to electric stimulation at the time of surgery; it should have spontaneously recovered. Long thoracic nerve repair is not indicated in C5 and C6 preganglionic injuries because C7 nerve root innervated the lower parts of the serratus anterior muscle, which acts as the strong abductor of the scapula. Most investigators recommend repair of the axillary nerve along with the suprascapular nerve.1,2,4 On the contrary, Hentz and Doi10 stated that the axillary nerve can be ignored because simple axillary nerve palsy does not result in serious paralysis of shoulder function. Biomechanically, the deltoid contributes to all phases of shoulder abduction, which can be supplemented by the other shoulder girdle muscles.10 The first phase of abduction (0° to 90° abduction) can be performed by the supraspinatus and the long head of the biceps; the second phase (90° to 150° abduction) and
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third phase (150° to 180° abduction) also can be performed by the trapezius and serratus anterior without the deltoid. Many authors10 concluded that there is no doubt that when the deltoid is completely paralyzed, it is possible for the patient to abduct the arm fully by supplemental action of the supraspinatus, the clavicular portion of the pectoralis major, and the long head of the biceps. In fact, our patient did not undergo axillary nerve repair and the deltoid muscle and teres minor muscle remained completely paralyzed. However, he obtained almost full range of motion and normal power strength of shoulder abduction, flexion, and external rotation. Not only the surgical procedure, but also the patient’s effort contributed to the unbelievable superior outcome. Although the quantitative measurement of strength decreased slightly, it was clinically unimportant. We therefore conclude that the suprascapular nerve is the first priority and that the long thoracic nerve rather than the axillary nerve is the second priority in shoulder reconstruction of C5, C6, and C7 preganglionic injuries.
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REFERENCES 1. Chuang DC, Lee GW, Hashem F, Wei FC. Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 1995;96:122–128. 2. Terzis JK, Kostas I. Suprascapular nerve reconstruction in 118 cases of adult posttraumatic brachial plexus. Plast Reconstr Surg 2006; 117:613– 629. 3. Uerpairojkit C, Leechavengvongs S, Witoonchart K, Malungpaishorpe K, Raksakulkiat R. Nerve transfer to serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus root avulsions. J Hand Surg 2009;34A:74 –78. 4. Bertelli JA, Ghizoni MF. Transfer of the accessory nerve to the
13. 14.
15. 16.
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suprascapular nerve in brachial plexus reconstruction. J Hand Surg 2007;32A:989 –998. Suzuki K, Doi K, Hattori Y, Pagsaligan JM. Long-term results of spinal accessory nerve transfer to the suprascapular nerve in uppertype paralysis of brachial plexus injury. J Reconstr Microsurg 2007; 23:295–299. Bernard F, Morrey EI, Kai-Nan A. Biomechanics of the shoulder. In: Rockwood CA, ed. The shoulder. 2nd ed. Philadelphia: Saunders, 1998:233–276. Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg 1994;19A:232–237. Oberlin C, Ameur NE, Teboul F, Beaulieu JY, Vacher C. Restoration of elbow flexion in brachial plexus injury by transfer of ulnar nerve fascicles to the nerve to the biceps muscle. Tech Hand Up Extrem Surg 2002;6:86 –90. Doi K. Management of total paralysis of the brachial plexus by the double free-muscle transfer technique. J Hand Surg 2008;33B:240 – 251. Hentz V, Doi K. Traumatic brachial plexus injury. In: Green DP, ed. Operative hand surgery. 5th ed. New York: Churchill Livingstone, 2005:1319 –1371. Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg 2001;26A:303–314. Allieu Y, Privat JM, Bonnel F. Paralysis in root avulsion of the brachial plexus: neurotization by the spinal accessory nerve. Clin Plast Surg 1984;11:133–136. Narakas AO. Thoughts on neurotization or nerve transfers in irreparable nerve lesions. Clin Plast Surg 1984;11:153–159. Doi K, Hattori Y, Ikeda K, Dhawan V. Significance of shoulder function in the reconstruction of prehension with double free-muscle transfer after complete paralysis of the brachial plexus. Plast Reconstr Surg 2003;112:1596 –1603. Bertelli JA, Ghizoni MF. Long thoracic nerve: anatomy and functional assessment. J Bone Joint Surg 2005;87A:993–998. Gregg JR, Labosky D, Harty M, Lotke P, Ecker M, DiStefano V, et al. Serratus anterior paralysis in the young athlete. J Bone Joint Surg 1979;61A:825– 832.
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Long Thoracic Nerve Neurotization for Restoration of Shoulder Function in C5-7 Brachial Plexus Preganglionic Injuries: Case Report Tetsuya Yamada, MD, Kazuteru Doi, MD, PhD, Yasunori Hattori, MD, PhD, Shushi Hoshino, MD, Soutetsu Sakamoto, MD, Yuichiro Arakawa, MD C5-7 brachial plexus preganglionic injuries are usually associated with complete paralysis of the long thoracic nerve. This makes it difficult to provide satisfactory shoulder function by neurotizing only the suprascapular nerve, compared with C5 and C6 preganglionic injuries, in which the long thoracic nerve is spared. We present a case report of a 21-year-old man who sustained a C5-7 brachial plexus preganglionic injury and obtained excellent shoulder function by intercostal nerve transfer to the long thoracic nerve in addition to neurotization of the suprascapular nerve. Our report emphasizes the importance of restoring the activity of the long thoracic nerve. (J Hand Surg 2010;35A:1427–1431. Copyright © 2010 by the American Society for Surgery of the Hand. All rights reserved.) Key words Brachial plexus, football, long thoracic nerve, shoulder function.
REVIOUS ARTICLES IN the literature have emphasized the value of suprascapular and axillary nerve repairs for reconstruction of shoulder abduction after upper-type paralysis of brachial plexus.1– 4 However, Suzuki et al.5 pointed out the importance of the long-thoracic nerve for shoulder abduction and flexion, because the range of active shoulder abduction after spinal accessory nerve to suprascapular nerve transfer without a functioning serratus anterior muscle is significantly less than one with a working serratus anterior muscle (p ⫽ .009). The relationship and contribution of the glenohumeral and scapulothoracic joints, the so-called scapulohumeral rhythm, allows the shoulder to move through its full range of elevation. Biomechanical studies have
P
FromtheDepartmentofOrthopedicSurgery,OgoriDaiichiGeneralHospital,Ogori,Yamaguchi,Japan. Received for publication March 14, 2010; accepted in revised form May 26, 2010. TheauthorsaregratefultoDr.AbhijeetL.Wahegaonkar,MD,forassistancewitheditingthisarticle. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Tetsuya Yamada, MD, Department of Orthopedic Surgery, Ogori Daiichi General Hospital, 862-3, Shimogo, Ogori, Yamaguchi City, Yamaguchi Prefecture, 754-0002, Japan; e-mail: [email protected]. 0363-5023/10/35A09-0004$36.00/0 doi:10.1016/j.jhsa.2010.05.024
shown a 2:1 ratio for overall glenohumeral-scapulothoracic motion.6 The serratus anterior muscle acts not only as an important mover of the scapulothoracic joint, but also as a stabilizer of the scapula. The serratus anterior muscle is innervated by the long thoracic nerve, which originates from the C5 to C7 nerve roots. In C5, C6, and C7 brachial plexus preganglionic injuries, therefore, the serratus anterior muscle is completely paralyzed. Treatment of this type of paralysis can restore satisfactory shoulder abduction only if combined with repair of the long thoracic nerve. On the other hand, in C5 and C6 preganglionic injuries, the lower part of the serratus anterior muscle is working. This type of paralysis shows an excellent outcome of shoulder abduction with repair of only the suprascapular nerve. Long thoracic nerve repair is imperative for C5, C6, and C7 preganglionic injuries to obtain satisfactory functional outcome. We present the successful use of intercostal nerve transfer to the long thoracic nerve to restore shoulder function in a patient with C5, C6, and C7 brachial plexus preganglionic injuries. CASE REPORT A 20-year-old right-handed man sustained a left brachial plexus injury when being tackled while playing
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1427
1428
C5-7 BRACHIAL PLEXUS PREGANGLIONIC INJURY
FIGURE 1: Preoperative photograph showing winging of the left scapula and atrophy of the infraspinatus and deltoid muscles.
football. He was referred to our clinic for further treatment 5 weeks after injury. Preoperative findings Clinically, the patient had winging of the left scapula (Fig. 1). The deltoid, supraspinatus, infraspinatus, and biceps brachii muscles were completely paralyzed and manual muscle testing of all these muscles, according to Medical Research Council Scoring, yielded a score of M0. Complete paralysis was confirmed by needle electromyography. The pectoralis major, triceps brachii, wrist, and finger extensor muscles were scored M4. The shoulder protraction test for evaluation of the serratus anterior muscle showed 2 finger breadths, which indicated complete paralysis. The patient had hypoesthesia in the C5, C6, and C7 dermatome distribution. Tinel’s sign was absent. Computed tomographic myelography revealed absence of the C5 and C6 roots and the presence of meningocele of the C7 root (Fig. 2). Surgery for exploration and spinal accessory nerve to suprascapular nerve transfer Ten weeks after the injury, the patient underwent brachial plexus exploration. We explored the C5, C6, and C7 nerve roots through a transverse cervical skin incision. The C5 and C6 nerve roots showed a neuroma in continuity. No muscular contraction was observed by electric stimulation of the C5 and C6 nerve roots. The C7 root was completely avulsed. We did not detect intraoperative evoked spinal cord potentials in C5 and
FIGURE 2: Preoperative computed tomographic myelography showing the absence of the left C5 and C6 roots and the presence of meningocele of the left C7 root, which implies root avulsion (arrow), and intact C8 and T1 roots.
C6 roots. The long thoracic nerve coming off the C5 and C6 roots immediately adjacent to the intervertebral foramina was identified. Contraction of the serratus anterior muscle did not occur with electric stimulation of the long thoracic nerve. Preoperative computed tomographic myelography and intraoperative findings and electrophysiological examination confirmed complete preganglionic injuries of the C5, C6, and C7 nerve roots. We explored the spinal accessory nerve through a transverse incision along the clavicle. The proximal branch of the spinal accessory nerve, which innervated to the upper part of the trapezius, was preserved, whereas the terminal branch of the nerve was divided as far distally as possible and transferred to the supraclavicular region. The suprascapular nerve arising from the C5 root was identified under the omohyoid muscle. The nerve was then transected at the point of its division from the C5 root and was directly anastomosed to the spinal accessory nerve stump in the supraclavicular fossa with epineural suture. At the same time, a single posteromedial fascicle of the ulnar nerve was transferred to the common branch of the musculocutaneous nerve for reconstruction of elbow flexion.7,8 Surgery for intercostal nerve to long thoracic nerve transfer Another 10 weeks after the first surgery, we performed third and fourth intercostal nerves to long thoracic nerve
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procedure then was carried out for harvesting the fourth medial intercostal nerve. After the dissection of the third and fourth intercostal nerve, each medial intercostal nerve was transferred to the long thoracic nerve at the third intercostal space (Fig. 3).
FIGURE 3: Intraoperative photograph and schematic drawing of the left chest wall before coaptation of the intercostal nerve to the long thoracic nerve. a, The third intercostal nerve. b, the long thoracic nerve. c, the fourth intercostal nerve.
transfer. The intercostal nerves and long thoracic nerve were exposed through an incision from the axilla and along the chest wall behind the pectoralis major to the level of the nipple. We identified the long thoracic nerve that courses down posterior to the midaxillary line. The third medial intercostal nerve could be found under the periosteum of the inferior margin of the third rib. We identified this nerve by tracing the lateral sensory branch of the intercostal nerve proximally. Dissection of the medial intercostal nerve was continued enough to reach the long thoracic nerve. A similar
Postoperative course One week after the surgery, passive exercise of shoulder and elbow joints was started. We used low-frequency electrical stimulation of the denervated muscles until electromyographic reinnervation was seen. Electromyographic reinnervation of the supraspinatus and biceps brachii muscles were detected at 3 months after surgery and the serratus anterior muscle was reinnervated at 5 months after surgery. After electromyographic documentation of the denervated muscles, electromyographic biofeedback techniques9 were started to train the reinnervated muscles to move the shoulder and elbow. After the medical rehabilitation, the patient came back to the university and trained the reconstructed upper limb by himself, with his team’s trainers. Two years after the surgery, the patient had no scapular winging and has achieved 180° of active shoulder flexion, 180° of abduction, and 60° of external rotation. Active range of motion of the elbow was 0° to 140° (Fig. 4). According to the 0 to 5 grading system for shoulder muscle strength, the patient demonstrated grade M4 muscle strength for flexion, abduction, and external rotation, although quantitative analysis of muscle strength for shoulder abduction using a Kin-Com (Chat-
FIGURE 4: Photograph 2 years after the surgery. A Full arm elevation and no winged scapula. B Elbow flexion and remaining atrophy of the deltoid muscle.
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FIGURE 5: The patient is able to throw the ball with the left involved hand.
tecx, Harrison, TN) dynamometer showed 30% of the contralateral normal side. The deltoid muscle remained completely paralyzed, which was proved by needle electromyography, because the axillary nerve had not been repaired. The patient resumed playing American football at his previous level and can play games as a quarterback (Fig. 5). DISCUSSION A lot of confusion and misunderstandings exist in upper-type brachial plexus injury concerning preoperative evaluation and postoperative functional outcomes. The most critical point is that preoperative paralysis is not classified strictly according to the level of injury and number of the injured root, although Hentz and Doi10 stated that there are marked differences in outcomes between C5 and C6 and the C5, C6, and C7 preganglionic injuries. The spinal accessory nerve is the donor nerve of choice to restore shoulder function.1,5,10,11 However, limited shoulder function was obtained in previous reports of spinal accessory nerve transfer to the suprascapular nerve, especially in C5, C6, and C7 preganglionic injuries.1,2,5,10 –13 Different investigators have shown that 20° to 60° of shoulder abduction may be achieved when using spinal accessory nerve to suprascapular nerve transfer.1,2,5,10,14 These differences in functional results arose because the investigators were not aware of the level of injury and number of involved roots, and especially the function of the serratus anterior
muscle. Hentz and Doi10 emphasized that C5, C6, and C7 preganglionic injuries should be distinguished from C5 and C6 preganglionic injuries when discussing evaluation of paralysis, the plan of reconstruction, and its outcome. The mean active ranges of shoulder motion after C5, C6, and C7 preganglionic injuries by spinal accessory nerve to the suprascapular nerve transfer without long thoracic nerve repair were 50.7° in flexion and 59.3° in abduction in our previous cases.5 In this case, our patient obtained an excellent outcome by intercostal nerve to long thoracic nerve transfer in addition to spinal accessory nerve to suprascapular nerve transfer, compared with our previous patients. The long thoracic nerve originates from C5 to C7 nerve roots in normal subjects. It is the sole innervation to the serratus anterior muscle, which stabilizes the scapula and provides upward and lateral rotation of the inferior angle of the scapula.15,16 In general, overall efforts to obtain 90° of shoulder abduction require approximately a 2:1 ratio of glenohumeral motion to this scapulothoracic motion. In preganglionic injuries of C5 and C6 nerve roots, the lower part of the serratus anterior muscle is working. The remaining innervated part of the serratus anterior stabilizes and moves the scapulothoracic joint and prevents winging of the scapula. On the other hand, in preganglionic injuries of the C5, C6, and C7 nerve roots, there is no functioning part of the serratus anterior muscle. Recently, Uerpairojkit et al.3 reported good results with combined nerve transfers: spinal accessory nerve to the suprascapular nerve, the nerve to the long head of the triceps to axillary nerve, and a branch of the thoracodorsal nerve to the long thoracic nerve in shoulder reconstruction of C5 and C6 preganglionic injuries. However, the long thoracic nerve should not have been paralyzed completely in C5 and C6 nerve root injuries even if it might not have reacted to electric stimulation at the time of surgery; it should have spontaneously recovered. Long thoracic nerve repair is not indicated in C5 and C6 preganglionic injuries because C7 nerve root innervated the lower parts of the serratus anterior muscle, which acts as the strong abductor of the scapula. Most investigators recommend repair of the axillary nerve along with the suprascapular nerve.1,2,4 On the contrary, Hentz and Doi10 stated that the axillary nerve can be ignored because simple axillary nerve palsy does not result in serious paralysis of shoulder function. Biomechanically, the deltoid contributes to all phases of shoulder abduction, which can be supplemented by the other shoulder girdle muscles.10 The first phase of abduction (0° to 90° abduction) can be performed by the supraspinatus and the long head of the biceps; the second phase (90° to 150° abduction) and
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third phase (150° to 180° abduction) also can be performed by the trapezius and serratus anterior without the deltoid. Many authors10 concluded that there is no doubt that when the deltoid is completely paralyzed, it is possible for the patient to abduct the arm fully by supplemental action of the supraspinatus, the clavicular portion of the pectoralis major, and the long head of the biceps. In fact, our patient did not undergo axillary nerve repair and the deltoid muscle and teres minor muscle remained completely paralyzed. However, he obtained almost full range of motion and normal power strength of shoulder abduction, flexion, and external rotation. Not only the surgical procedure, but also the patient’s effort contributed to the unbelievable superior outcome. Although the quantitative measurement of strength decreased slightly, it was clinically unimportant. We therefore conclude that the suprascapular nerve is the first priority and that the long thoracic nerve rather than the axillary nerve is the second priority in shoulder reconstruction of C5, C6, and C7 preganglionic injuries.
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