Functioning transferred free muscle innervated by part of the vascularized ulnar nerve connecting the contralateral cervical seventh root to themedian nerve: Case report
© Kakinoki et al. 2007
Received: 03 May 2007
Accepted: 21 September 2007
Published: 21 September 2007
The limited nerve sources available for the reconstruction and restoration of upper extremity function is the biggest obstacle in the treatment of brachial plexus injury (BPI). We used part of a transplanted vascularized ulnar nerve as a motor source of a free muscle graft.
A 21-year-old man with a left total brachial plexus injury had received surgical intercostal nerve transfer to the musculocutaneous nerve and a spinal accessory nerve transfer to the suprascapular nerve in another hospital previously. He received transplantation of a free vascularized gracilis muscle, innervated by a part of the transplanted vascularized ulnar nerve connecting the contralateral healthy cervical seventh nerve root (CC7) to the median nerve, and recovered wrist motion and sensation in the palm. At the final examination, the affected wrist could be flexed dorsally by the transplanted muscle, and touch sensation had recovered up to the base of each finger. When his left index and middle fingers were touched or scrubbed, he felt just a mild tingling pain in his right middle fingertip.
Part of the transplanted vascularized ulnar nerve connected to the contralateral healthy cervical seventh nerve root can be used successfully as a motor source and may be available in the treatment of patients with BPI with scanty motor sources.
The limited nerve sources available for the reconstruction and restoration of upper extremity function is the biggest obstacle in the treatment of brachial plexus injury (BPI). Recently, there have been several techniques invented to solve this. One is the use of the contralateral healthy cervical seventh nerve root (CC7) reported by Gu et al. in 1992 . They used this as a donor nerve to reconstruct the median nerve function of the affected arm. Another is the use of a part of the ulnar nerve transfer for reinnervation of the biceps brachii muscle for the treatment of upper type BPI reported by Oberlin et al. in 1994 . Several authors have reported excellent outcomes for nerve recovery with the use of these techniques without leaving functional loss of the donor nerves [3–7].
We describe a 21-year-old patient with BPI who received a vascularized free gracilis muscle transfer  innervated by a part of the vascularized ulnar nerve connecting CC7 to the affected median nerve. This successfully restored wrist motion and sensation to the palm.
Twelve months after the BPI surgery performed in the previous hospital, he visited our clinic complaining of complete loss of sensation and motor function distal to the left elbow joint. Reasonable recovery of the shoulder and elbow joints was seen from a physical examination. The left elbow flexion range was 100° against gravity and the abduction and flexion ranges of the left shoulder against gravity were 80° and 85°, respectively. However, the elbow extension was M0 according to the Medical Research Council Scale (MRCS) and the range of left shoulder extension was 15°, which was mostly achieved by motion of the left scapula. No active motion was observed in the left wrist and fingers. The patient demonstrated complete numbness in the area innervated by the left C5-T1 nerve roots. He had slight stiffness in the MP joints of the left index finger to the little finger, and started rehabilitation exercises to soften the joints. No other joints of his left upper extremity showed restriction of the range of motion in the passive movement. Elbow flexion was recovered to M4 level according to MRCS at 15 months after surgery thanks to muscle-strengthening exercises.
As the final stage of the reconstruction, we plan to perform biceps brachii muscle transfer to the triceps muscle to stabilize the elbow joint, tenodesis at the wrist and arthrodesis of the thumb to obtain pinch function. The patient has not yet agreed to final operation, because he is completely satisfied with the improved muscle strength of the elbow flexion and is worried about possible loss of elbow flexion strength after the biceps brachii muscle transfer.
This patient with BPI involving the total brachial plexus had undergone intercostal nerve transfer  to the musculocutaneous nerve and a spinal accessory nerve transfer  to the suprascapular nerve in a previous hospital. We restored sensation of the palm and motion of the wrist to the patient by transplantation of a vascularized ulnar nerve between the CC7 and the median nerve and a free vascularized gracilis muscle innervated by a part of the transplanted vascularized ulnar nerve. Nineteen months after our first operation, the affected wrist was flexed dorsally by the transplanted muscle innervated by a part of the vascularized nerve connecting to the CC7 and touch sensation recovered up to the base of each fingers.
Several authors have reported excellent outcomes of the sensory and motor recovery of the median nerve using a vascularized nerve transfer connected to the CC7 [1, 3, 5, 7]. Poor motor recovery is to be expected in muscles denervated for more than six months, and skin sensation does not recover if it has been denervated for a long time, because its muscle fibers or sensory organs become too atrophied [11, 12]. In our patient, median nerve reconstruction was performed 16 months after the original injury. Excellent recovery of the sensory and motor function of the median nerve could not be expected in this patient, even with CC7 transfer to the median nerve. Thus, it was controversial whether this patient had a valid indication for a CC7 transfer to reconstruct the median nerve. Moreover, for this patient no motor source was available without the vascularized nerve connecting CC7. The intercostal nerves and the accessory nerve had already been used to restore elbow flexion and shoulder mobility. The patient had left phrenic nerve palsy. The patient had no chance of motor recovery without using a free functioning muscle transfer, as no muscles in the affected arm would function even after the neurotization because of the prolonged loss of innervation. Therefore, we decided to perform a CC7 transfer to the median nerve, expecting it to serve as the motor source of a free functioning muscle transfer as well as for recovery of the sensation of the hand. Because a movable hand lacking sensation is no more harmful than a totally paralyzed hand, we reached a consensus with the patient before surgery that the free gracilis muscle transfer would not be done if the sensory recovery of the median nerve was poor. Actually, the patient showed more rapid and better sensory recovery in the median nerve than we had expected before the CC7 operation. Four months after the operation, the patient recognized touch sensation up to the midpalm level of the hand. The sensory recovery of this patient was extremely faster than that reported by previous authors [1, 3, 5, 7]. Although there may be different opinions , one possible explanation of the rapid nerve recovery through the CC7 operation in this patient is that the nerve recovery in the transplanted ulnar nerve might have been accelerated by sufficient vascular supply supercharged by the accompanying ulnar artery connected to the transverse cervical artery in the right neck. Most previous authors performed CC7 operations without supercharging the ulnar vessels accompanying the transplanted ulnar nerve [1, 3, 5]. In addition, the patient was still 22 years old when he had the CC7 operation. His youth might have also contributed to his rapid sensory recovery of his affected median nerve.
Several surgeons have treated patients with upper BPI using a part of the ulnar nerve transferred to the biceps brachii branch of the musculocutaneous nerve and have demonstrated rapid reinnervation of the biceps brachii muscles without leaving any functional loss in the donor ulnar nerve [2, 4, 6, 10]. Oberlin et al. reported that no functional loss should occur in the ulnar nerve after partial ulnar transfer, because the nerve fibers are still mixed and their locations are not distributed functionally at the midarm level . In our patient, no regression of the sensation of the affected hand was observed after a part of the vascularized nerve was transferred to a branch innervating the free transplanted muscle. A part of the transplanted ulnar nerve was taken in the subclavicular region and joined to the obturator nerve of the transplanted gracilis muscle. The ulnar nerve was sectioned just above the insertion of the superior ulnar collateral vessels to the ulnar nerve, and the distal portion of the nerve was reflected proximally in the CC7 operation. Thus, the portion where a part of the transplanted ulnar nerve had been harvested was almost the same as where a part of the ulnar nerve had been taken in Oberlin's original procedure . Because the nerve fibers had not been distributed functionally in the portion where a part of the transplanted ulnar nerve was taken, the palmar sensation in this patient after harvesting a part of the transplanted nerve may not have been compromised.
In conclusion, part of the transplanted vascularized ulnar nerve connected to the contralateral healthy cervical seventh nerve root can be used successfully as a motor source and may be available in the treatment of patients with BPI with scanty motor sources.
We obtained the patient's permission to submit this article to Journal of Brachial Plexus and peripheral nerve injury.
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