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Hemi-Contralateral C7 Transfer in Traumatic Brachial Plexus Injuries: Outcomes and Complications
Douglas M. Sammer, MD1; Michelle F. Kircher, RN, BSN2; Allen T. Bishop, MD2; Robert J. Spinner, MD2; Alexander Y. Shin, MD2
1 Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390
2 Departments of Orthopedic Surgery (M.F.K., A.T.B., and A.Y.S.) and Neurosurgery (R.J.S.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for A.Y. Shin: shin.alexander@mayo.edu
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Investigation performed at the Mayo Clinic, Rochester, Minnesota



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jan 18;94(2):131-137. doi: 10.2106/JBJS.J.01075
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Abstract

Background: 

In brachial plexus injuries with nerve root avulsions, the options for nerve reconstruction are limited. In select situations, half or all of the contralateral C7 (CC7) nerve root can be transferred to the injured side for brachial plexus reconstruction. Although encouraging results have been reported, CC7 transfer has not gained universal popularity. The purpose of this study was to critically evaluate hemi-CC7 transfer for restoration of shoulder function or median nerve function in patients with severe brachial plexus injury.

Methods: 

A retrospective review of all patients with traumatic brachial plexus injury who had undergone hemi-CC7 transfer at a single institution during an eight-year period was performed. Complications were evaluated in all patients regardless of the duration of follow-up. The results of electrodiagnostic studies and modified British Medical Research Council (BMRC) motor grading were reviewed in all patients with more than twenty-seven months of follow-up.

Results: 

Fifty-five patients with traumatic brachial plexus injury underwent hemi-CC7 transfer performed between 2001 and 2008 for restoration of shoulder function or median nerve function. Thirteen patients who underwent hemi-CC7 transfer to the shoulder and fifteen patients who underwent hemi-CC7 transfer to the median nerve had more than twenty-seven months of follow-up. Twelve of the thirteen patients in the shoulder group demonstrated electromyographic evidence of reinnervation, but only three patients achieved M3 or greater shoulder abduction motor function. Three of the fifteen patients in the median nerve group demonstrated electromyographic evidence of reinnervation, but none developed M3 or greater composite grip. All patients experienced donor-side sensory or motor changes; these were typically mild and transient, but one patient sustained severe, permanent donor-side motor and sensory losses.

Conclusions: 

The outcomes of hemi-CC7 transfer for restoration of shoulder motor function or median nerve function following posttraumatic brachial plexus injury do not justify the risk of donor-site morbidity, which includes possible permanent motor and sensory losses.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    References

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    Yu-Dong GU, M.D.; Cheng-Gang ZHANG, M.D.,Ph.D.
    Posted on March 12, 2012
    Reiteration of key factors for the success of CC7 transfer
    Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Key Laboratory of Peripheral Nerve and Microsurgery; all, Shanghai

    We read this paper with great interest. The authors performed hemi-CC7 transfer in a single stage manner and gained unrewarding motor recovery. (We have to say it is indeed a pity that the authors failed to document the sensory recovery in the median nerve repair group, which was one of the main goals in CC7 transfer. A number of studies have demonstrated CC7 transfer is effective and reliable in restoring hand sensation[1-6]). Based upon their own disappointing outcome, the authors came to the conclusion that CC7 transfer does not justify the risk of potential donor-site morbidity. As the first institution to introduce this technique, we feel obliged to point out that the techniques the authors adopted in their series of patients were not optimal and we would like to reiterate a few key factors to the success of CC7 transfer, based upon our over 25 years of experience[7].Effectiveness of hemi-contralateral C7 nerve transfer: The poor outcome after hemi-contralateral C7 transfer has already been demonstrated over a decade ago by Thailand surgeons[5,6]. In our early and recent studies we compared the effectiveness of entire C7 and hemi-contralateral C7 transfer and favorable results were obtained in the entire C7 group[1,4,8]. Besides, the safety of dividing entire C7 nerve has been widely reported and accepted (Gu 50 cases, 1994[9]; Dong 30 cases, 1997[10]; Liu 2 cases, 1997[11]; Chuang 21 cases, 1998[12]; Waikakul 96 cases, 1999[6]; Sungpet 24 cases, 1999[13]; Songcharoen 111 cases, 2001[5]; Hierner 10 cases, 2007[14]; Terzis 56 cases, 2009[2]; and Chuang 101 cases, 2012[3]; none of these authors reported permanent functional loss in the healthy limb),and in our vast experience of more than 1000 cases of contralateral C7 transfer since 1986, permanent motor or sensory deficit was never encountered. Among a total of 56 cases, the authors had one case that experienced permanent motor and sensory loss which required tendon transfer eventually. This appears to be the sole report of such severe complications after CC7 transfer, and it is still unclear whether this occurred secondary to technical error. In short, entire C7 transection is safe and since donor axons are never sufficient in reconstruction of a total avulsed brachial plexus, we strongly advocate using entire contralateral C7 nerve to ensure providing maximum number of axons for motor and sensory restoration. Staging of contralateral C7 nerve transfer: Blood supply is essential to successful nerve regeneration[15,16], especially in CC7 transfer where the length of the nerve graft typically exceeds 30 cm in adults, and staged procedure can preserve good blood supply to the pedicled nerve graft. Therefore, we insist on performing CC7 transfer in two separate stages. In first stage, the distal end of the pedicled vascularised ulnar nerve graft was reversed and connected with contralateral C7 via a cross-chest subcutaneous tunnel. Particular attention needs to be paid while dissecting the ulnar nerve above the elbow to protect the blood supply from superior ulnar collateral vessels, and usually 4-8 months are allowed for regeneration before the second operation is undertaken to transfer the regenerated ulnar nerve to the recipient nerve[4]. If the proximal end of the ulnar nerve is divided and transferred immediately to the target nerve in one stage, the fibrosis at this nerve suture site will take place before regenerated fibres from the contralateral side reach this location, which will block regeneration. Additionally, our experimental data also proved that the staged procedure resulted in better recovery[17]. Therefore, single stage CC7 transfer will harm the blood supply to the ulnar nerve graft and will inevitably jeopardize the final functional outcome and should be avoided. The importance of good blood supply and the effectiveness & safety of using entire C7 have been supported by the recent reports from Terzis and Chuang, who both achieved good hand sensation and motor recovery[3,18]. Total brachial plexus root avulsion leaves a complete flail arm. To someone who has nothing, a little means a lot. Our patients are grateful when they have regained hand sensation and some motor recovery in the previously paralyzed limb and do not regret the extensive surgery they have gone through. We firmly believe contralateral C7 transfer is beneficial to such patients and through refinement of techniques, we will continue to perform contralateral C7 transfer. REFERENCES: [1] Gu YD, Chen DS, Zhang GM, Cheng XM, Xu JG, Zhang LY, Cai PQ, Chen L. Long-term functional results of contralateral C7 transfer. J Reconstr Microsurg. 1998;14(1):57–9. [2] Terzis JK, Kokkalis ZT. Selective contralateral C7 transfer in posttraumatic brachial plexus injuries: a report of 56 cases. Plast Reconstr Surg. 2009;123(3):927–38. [3] Chuang DC, Hernon C. Minimum 4-year follow-up on contralateral c7 nerve transfers for brachial plexus injuries. J Hand Surg Am. 2012 Feb;37(2):270-6. [4] Gao KM, Lao J, Zhao X, Gu YD. Long-term outcome of selective contralateral C7 nerve transfer. Chin J Hand Surg (Chin) 2010;26(6):324–7. [5] Songcharoen P, Wongtrakul S, Mahaisavariya B, Spinner RJ. Hemi-contralateral C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury. J Hand Surg Am. 2001 Nov;26(6):1058-64. [6] Waikakul S, Orapin S, Vanadurongwan V. Clinical results of contralateral C7 root neurotization to the median nerve in brachial plexus injuries with total root avulsions. J Hand Surg Br. 1999 Oct;24(5):556-60. [7] Zhang CG, Gu YD. Contralateral C7 nerve transfer - Our experiences over past 25 years. J Brachial Plex Peripher Nerve Inj. 2011 Nov 23;6(1):10. [8] Gu YD, Zhang GM, Chen DS, Yan JG, Cheng XM, Chen L. Seventh cervical nerve root transfer from the contralateral healthy side for treatment of brachial plexus root avulsion. J Hand Surg Br. 1992;17(5):518–21. [9] Gu YD. Distribution of the sensory endings of the C7 nerve root and its clinical significance. J Hand Surg (Br) 1994;19(1):67–8. [10] Dong Z, Cheng XM, Gu YD. The regular pattern of early sensory and motor changes of the healthy hand after C7 transfer and its clinical significance. Chin J Hand Surg (Chin) 1997;13(1):242–4. [11] Liu J, Pho RW, Kour AK, Zhang AH, Ong BK. Neurologic deficit and recovery in the donor limb following cross-C7 transfer in brachial-plexus injury. J Reconstr Microsurg. 1997 May;13(4):237-42. [12] Chuang DC, Cheng SL, Wei FC, Wu CL, Ho YS. Clinical evaluation of C7 spinal nerve transection: 21 patients with at least 2 years' follow-up. Br J Plast Surg. 1998 Jun;51(4):285-90. [13] Sungpet A, Suphachatwong C, Kawinwonggowit V. Sensory abnormalities after the seventh cervical nerve root transfer. Microsurgery. 1999;19(6):287-8. [14] Hierner R, Berger AK. Did the partial contralateral C7-transfer fulfil our expectations? Results after 5 year experience. Acta Neurochir Suppl. 2007;100:33–5. [15] Chen L, Gu YD. An experimental study of contralateral C7 nerve root transfer with vascularised nerve grafting to treat brachial plexus root avulsion. J Hand Surg (Br) 1994;19(1):60–6. [16] Xu J, Gu YD, Lao J. Anatomical basis of vascularised ulnar nerve graft by the pedicle of the superior collateral ulnar artery. Chin J Traumatology. 2001;4:195-8. [17] Lao J, Xiong LJ,Gu YD.,Mang YH. Optimal time of contralateral side C7 root transfer for brachial plexus root avulsion: an experimental study. Chin J Hand Surg. 1995;11:165-7. [18] Terzis JK, Kostopoulos VK. Vascularized ulnar nerve graft: 151 reconstructions for posttraumatic brachial plexus palsy. Plast Reconstr Surg. 2009;123(4):1276–91.

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