Ovid_ Technique of Inter...Achial Plexus Injuries

8/11/2019 Ovid_ Technique of Inter...Achial Plexus Injuries

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INDICATIONS AND CONTRAINDICATIONS

Neurotization is indicated in cases of brachial plexus traction injuries with complete avulsion of the spinal

nerve roots or irreparable proximal lesions of spinal nerves. A proper evaluation of brachial plexus lesions is a

prerequisite to any reconstructive procedure. Intercostal nerves most frequently have been used to neurotize

the musculocutaneous nerve 2,8,9,12,15,22-24,27,34for rec onstruction of elbow flexion. It can also be used to

neurotize the branch o f the radial nerve to the tric eps for reco nstruction of elbow extension 14,28,35or to

neurotize a free-functioning muscle transfer.6,35-41Hand sensibility can be restored by suturing the sensory rami

of the intercostal nerves to the medial head of the median nerve or the ulnar nerve component of the medial

cord.40,42Other reported uses of intercostal nerve neurotization have been to reanimate the diaphragm in

patients confined to long-term positive-pressure ventilation because of high cervical spine injury,33for

reconstruc tion in a case of Poland's syndrome,31and for dynamic reconstruction of the abdominal wall using a

reinnervated free rectus femoris muscle transfer.32Although advanced age is not a contraindication, better

results have been obtained in younger patients,27,43those with a shorter time interval between injury and

surgery,8,43and the use of direct transfer without the use of interposition nerve grafts.8,15,26There has been

some conce rn about reduced pulmonary function after intercostal nerve transfer, but c linical studies have

proved otherwise.17,44,45

Cases with ipsilateral phrenic nerve palsy and rib fractures are con traindications to the procedure . Poor

local skin conditions and thoracic vertebral fractures are relative contraindications.

Intercostal nerve transfer is a technically demanding procedure and should be unde rtaken by surgeons

experienced in this technique. A cooperative patient who understands and c an follow the protracted c ourse of

physiotherapy is another prerequisite for this operation.46,47

SURGICAL ANATOMY OF THE SECOND TO SIXTH VENTRAL THORACIC RAMI

The second to sixth thoracic ventral rami proceed in their intercostal spaces below the interco stal vessels

(Fig. 1). Posteriorly, they are between the pleura and posterior intercostal membranes but, in most of their

course, run be tween the internal intercostals and the subcostalis and interc ostalis intimi. Near the sternum, they

cross anterior to the internal thoracic vessels and the transversus thoracis and pierce the internal intercostals,

external intercostal membrane, and pectoralis major, ending as the anterior cutaneous nerves of the thorax,

which supply the skin on the front of the thorax (Fig. 2). The second anterior cutaneous nerve may be

connected to the medial supraclavicular nerves, and twigs from the sixth supply the abdominal skin in the upper

part of the infrasternal angle.48


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FIGURE 1. Schematic of neurovascular relations in a typical intercostal space. Intercostal vein (gray arrow),

intercostal artery (black arrow), and intercostal nerve (black arrowhead).


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FIGURE 2. Schematic of the course and distribution of the intercostal nerve.

BRANCHES

Numerous muscular rami supply the intercostals, serratus posterior superior, and transversus thoracis.

Anteriorly, some cross the costal cartilages from one intercostal space to another. From each intercostal nerve, a

collateral and a lateral cutaneous branch leave before the main nerve reaches the costal angle. The collateral

branch follows the inferior border of its space in the same intermuscular plane as the main nerve, which it may

rejoin before distribution as an additional anterior cutaneous nerve. The lateral cutaneous branch accompanies

the main nerve a little way and then pierces the intercostal muscles obliquely; except for the first and second,

each divides into anterior and posterior rami which pierce the serratus anterior. Anterior branches run forward

over the border of the pectoralis major to supply the overlying skin, the fifth and sixth also supplying twigs to a

variable number of upper digitations of the obliquus abdominis externus. Posterior branches run back to supply

the skin over the scapula and latissimus dorsi. The second lateral cutaneous branch is the intercostobrachial

nerve. It crosses the axilla to the medial side of the arm, joins with a branch of the medial cutaneous nerve of

the arm, pierces the deep fascia, and supplies the skin of the upper half of the posterior and medial aspects of

the arm, connecting with the posterior c utaneous branch of the radial nerve. A second intercostobrachial nerve

often branches off from the anterior part of the third lateral cutaneous nerve supplying the axilla and the medial

side of the arm.

NEUROVASCULAR ARRANGEMENT WITHIN THE INTERCOSTAL SPACE

Each intercostal artery crosses its intercostal space obliquely toward the angle of the rib above and

continues forward in its costal groove. At first between the pleura and internal (posterior) intercostal membrane

as far as the costal angle, it passes between the intercostalis internus and intercostalis intimus muscles,

anastomosing with an anterior intercostal branch from an internal thoracic or musculophrenic artery. It has a vein

above and a nerve below (Fig. 1), except in the upper spaces where the nerve is at first above the artery. Each

posterior intercostal artery has dorsal, collateral, muscular, and cutaneous branches.49


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TECHNIQUE

Anesthesia, Patient Positioning, and Planning

With the patient under general anesthesia in the supine position, the arm is placed on a hand table with the

shoulder in approximately 50 to 60 degrees of abduction (Fig. 3). The body is tilted 20 degrees to the unaffected

side, by interposing a pillow under the chest wall of the affected side. The shoulder is not abducted as much in

case a free muscle transfer has been done earlier to prevent tension on the transferred muscle. Alternatively,

the upper extremity can be supported with rolled towels on the operating table with a small arm rest. This allows

more room for the operating team by eliminating the need for a side table.

FIGURE 3. Patient positioning after anesthesia.

Technique of Intercostal Nerve Harvest

The incision extends along the lower edge of the pectoralis major muscle from the anterior axillary fold

toward sternum. It is slightly gently curved medially toward the xiphoid process (Fig. 4). In women, the incision is

carried along the inframammary fold for better cosmesis. The exposure of the third to the sixth intercostal

spaces is done in the same way as described he re. The skin and the subc utaneous tissue are incised using a

scalpel and electrocautery, respectively, and flaps are developed on either side of the incision. The

intercostobrachial nerves are identified and tagged for later transfer to the medial head of the median nerve. The

fascia over the lower border of the pectoralis major muscle is then incised, and the muscle is carefully dissected

and retracted. This brings into view the pectoralis minor muscle which lies immediately below the major. The

origin of the pectoralis minor muscle serves as an important and useful landmark for the identification of the

third, fourth, and fifth ribs (Figs. 5 A, B). The ribs are identified, and the soft tissue and periosteum are incised

with a Bovie over the anterior surface of the rib in the midline from the midaxillary line to the costochondral

junction (Fig. 6). Each rib is then carefully freed of the periosteum with a periosteum elevator. The periosteum is

lifted off over the anterior surface first in the direction of the fibers and then over the posterior aspect with a

curved periosteum elevator and a rib raspatory (Figs. 7 A-D). Each rib is thus completely dissected and denuded of


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its periosteal cover. Except in cases where the re are antecedent rib fractures, the dissection with a curved

sharp periosteum elevator is relatively easy and straightforward, and injury to the pleura is exceptional. In the

rare case of the pleura being cut or damaged during dissection, there is usually sufficient soft tissue on the

posterior aspect of the rib for an immediate tensionless closure of the pleural breach with a fine monofilament

suture. Usually, no drainage is necessary if the patient is maintained on positive-pressure ventilation. The

approach and exposure of the intercostal nerve require prec ision and c areful dissection. The denuded rib is

elevated with a Farabeuf retractor or 2 hooks by the assistant. Another assistant then grips and retracts the free

edge of the periosteum with a pair of Kocher forceps toward him. A longitudinal incision is then made over the

deep surface of the periosteum, medial to the midclavicular line, with a no. 15 scalpel (Figs. 8A, B). At this level,

the intercostal muscles are thin, and the nerve is easier to identify. As soon as the nerve is visualized, coursing

underneath the transparent endothoracic fascia, it is carefully dissected using fine Stevens scissors and isolated

with a silicone loop. At no point during the dissection the nerve is directly gripped with the forceps. It is simply

raised gently by the silicone loop. Upon isolation, the intercostal nerve is stimulated with a nerve stimulator toconfirm its motor branch (Fig. 9). Each small collateral branch of the nerve is carefully dissected with the scissors.

Most importantly, electrocoagulation is not used for hemostasis until the entire length of the nerve is dissected

and the distal end is sectioned; the nerve is reversed toward the axillary area. In the event of any bleeding or

hemorrhage during the dissection, the corner of the gauze pad is simply packed on the hemorrhagic zone, and

the dissection is continued. This simple precaution helps avoid any inadvertent injury to the delicate intercostal

nerve. Depending on the length of the intercostal nerve required to reach the recipient nerve, the dissection

may be extended medially up to the costochondral junction. Laterally, the dissection is carried to the deep

surface of the insertion of the serratus anterior digitations. We prefer and advocate pre serving the serratus

insertion when it is not completely paralytic or has been reinnervated during surgery (Fig. 10). Intercostal nerve

transfer reach toward the recipient nerve is facilitated by passing the nerves through a tunnel created in the

muscle. The intercostal nerves are then assembled together on a plastic background material and carefully

resized and recut under an operating microscope. Interfascicular suture is carried out using 10-0 or 11-0

monofilament nylon sutures (Fig. 11). We usually put in 4 to 5 sutures, and we do not use fibrin glue. In our

experience, 2 intercostal nerves put together match the diameter of the branch of the radial nerve to the long

head of the triceps, and 3 intercostal nerves form a good match with the branch of the musculocutaneous nerveto the biceps. The suture is made with slight abduction of the shoulder, so that during the postoperative

immobilization, the risk of tension on the nerves is reduced considerably. A meticulous hemostasis is done. The

muscles and fascia over the ribs are sutured together with nonabsorbable sutures to prevent any dead space and

later seroma formation. The incision is closed in layers over a Penrose drain away from the neurorrhaphy site in

the dependent region to prevent any postoperative hematoma formation (Fig. 12). It is very important to prevent

any rubbing of the skin during cleaning of the blood stains postoperatively because the neurorrhaphy is very

susceptible to shear forces. Therefore, the skin is gently mopped and dabbed with saline-soaked sponges. Strict

immobilization is done for 3 weeks using a soft pillow support splint (Fig. 13). Passive abduction of the shoulder is

prohibited for another 2 months.

FIGURE 4. Preparation of the surgical field and the planned skin incision. Note the arm supported with rolled

towels.

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FIGURE 5. A, Schematic of the origin of the pectoralis minor muscle from the third, fourth, and fifth ribs. B, The

pectoralis major (small arrow) has been retracted for the identification of the pectoralis minor (small arrow). Note

the tagged intercostobrachial nerve (arrowhead).


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FIGURE 6. Inscision of the fascia and periosteum over the anterior surface of the third through fifth ribs (arrows).

FIGURE 7. Stripping off the rib periosteum from (A) the anterior surface and (B and C) the posterior surface using

a curved periosteum elevator and a rib raspatory, respectively. D, Schematic of the periosteal dissection.


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FIGURE 8. A, Intraoperative view showing the simultaneous retraction and elevation of the rib (small arrow) toimprove visualization of the undersurface and the stripped periosteum in its entirety (arrowhead). The second

assistant retracts the periosteum held firmly with a pair of Kocher forceps (large arrows). The surgeon then

makes an incision on the periosteum to identify and isolate the intercostal nerve. B, Schematic of this step in the

surgery.


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FIGURE 9. The intercostal nerve is identified, tagged, and dissected free (arrow). It is stimulated with a nerve

stimulator to confirm the motor branch (black arrowhead).

FIGURE 10. Schematic of the intercostal nerves tunneled through the serratus anterior muscle slips while stillpreserving its insertion.


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FIGURE 11. The motor branches of the intercostal nerve have been sutured to the musculocutaneous ne rve

(arrowhead), whereas the sensory rami and the intercostobrachial nerves have been transferred to the medial

head of the median nerve for sensory reconstruction (small arrow).

FIGURE 12. Skin closure and placement of Penrose drains (arrowheads).


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FIGURE 13. Immediate postoperative immobilization with "controlled" abduction of the ipsilateral shoulder with a

cushion pillow splint.


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COMPLICATIONS

With proper surgical technique and meticulous dissection, complications are a rare o ccu rrence. In our

experience, the most common complication has been the formation of a seroma or the collection of an effusion.

This can be prevented by c areful closure of the incision in layers and the strategic placement of Penrose drains

in the dependent part of the incision. It is especially important to carefully suture the intercostal muscles which

have been elevated off the ribs to prevent the formation of any dead space. Another complication that might

occur is iatrogenic pneumothorax while dissecting out the intercostal nerve. We have had 2 cases of

pneumothorax formation, which were immediately managed by chest tubes and positive end-expiratory pressure

ventilation with no postoperative sequelae. When detected, the rent in the pleura should be immediately closed

with fine monofilament nylon or Prolene using an atraumatic round-bodied needle.

POSTOPERATIVE PROTOCOL

The arm on the operated side is immobilized in controlled slight abduction so as not to place excessive

tension on the neurorrhaphy site with a commercially available soft pillow splint. A chest radiograph is taken

before the patient is transferred to the recovery unit to rule out any pneumothorax. The arm is maintained in

this position of immobilization for a period of 3 weeks. Supervised gentle, passive, range-of-motion exercises are

commenced thereafter, but any abduction of the shoulder is prevented for a further 2 months. Postoperative

rehabilitation program varies according to the purpose for which the intercostal nerve transfer was performed.

But, essentially, the patient is trained to achieve contraction of the reinnervated muscle by deep breathing

exercises and is then progressively trained to achieve independent c ontraction of the reinnervated muscle.50,51

The recovery after intercostal nerve transfer is monitored clinically by eliciting the Tinel sign and by

electromyography. We have observed that audiovisual biofeedback exercise using electromyography is very

effective for a patient to know which effort is best to achieve efficient muscle contraction and to learn how tocontinue the contraction.46,47,52The details of the rehabilitation program are beyond the scope of this article

and shall be described elsewhere in the near future.

OUTCOMES

Chuang et al 8have reported a success rate of up to 81% in 66 patients with brachial plexus injuries treated

by means of intercostal nerve transfer to the musculocutaneous nerve, with or without nerve grafts to obtain

elbow flexion. Krakauer and Wood 11reported that useful elbow function was obtained in of 9 of 13 patients with

traumatic brachial plexopathy who underwent intercostal nerve transfer to the biceps motor branch (9 patients)

or combined gracilis muscle and intercostal nerve transfer (4 patients). They concluded that intercostal nerve

transfer and combined gracilis muscle and intercostal nerve transfer are viable, although technically demanding,

alternatives for restoring active elbow motion in patients with irreparable brachial plexus lesions when

conventional tendon transfers are not feasible. Malessy and Thomeer 15performed direct coaptation of the

intercostal nerve to the musculocutaneous nerve in 25 patients and obtained useful elbow flexion in 64% of the

patients. Other studies in the literature have reported successful results varying from 50% to 87%.12,16,53,54

Merrell et al 26performed a meta-analysis of the English literature, designed to quantitatively assess the efficacy

of individual nerve transfers for restoration of elbow and shoulder function. One thousand eighty-eight nerve

transfers from 27 studies met their inclusion criteria of the analysis. Seventy-two percent of direct intercostal to

musculocutaneous transfers (without interposition nerve grafts) achieved biceps strength equal to M 3 or more

versus 47% using interposition grafts. They concluded that interposition nerve grafts should be avoided when

possible when performing nerve transfers. Better results for restoration of elbow flexion were obtained with

intercostal to musculocutaneous transfers than with spinal accessory nerve transfers. This finding is also

supported by an experimental study by Hattori et al.55The results of intercostal nerve transfer in our institution

parallel those reported in the literature. However, in a more recent study, Matejcik 56reported very poor

results of intercostal nerve transfer for elbow flexion in 7 patients with not a single patient recovering any useful

function of the elbow. He c oncluded that the time gap between the injury and the operation, the level and the

extent of the nerve injury, and the type of the reconstruc tive procedure are the main prognostic factors for the

functional recovery of the paralyzed muscles, resulting from brachial plexus traction injury.

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52. Kawai H, Murase T, Shibuya R, et al. Magnetic stimulation of biceps after intercostal cross-innervation for

brachial plexus palsy. A study of motor evoked potentials in 25 patients. J Bone Joint Surg Br. 1994;76: 666-669.


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55. Hattori Y, Doi K, Fuchigami Y, et al. Experimental study on donor nerves for brachial plexus injury: comparison

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Keywords: brachial plexus injury; intercostal nerve transfer; technique

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Ovid_ Technique of Inter...Achial Plexus Injuries