Abstract BACKGROUND AND IMPORTANCE The use of nerve transfers to restore nerve function following traumatic avulsion injuries has been described, though there is still a paucity in the literature documenting technique and long-term outcomes for these procedures. The double Oberlin nerve transfer involves transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve to restore elbow flexion in patients with a C5-C6 avulsion injury. The purpose of this case report is to present our indications and technique for a double Oberlin transfer in addition to exhibiting video footage at follow-up time points documenting the incremental improvement in elbow flexion following the injury. CLINICAL PRESENTATION The patient is a 25-yr old, left-hand dominant male who presented 5 mo following a motor vehicle accident. He had 0/5 biceps muscle strength on the left with a computed tomography myelogram that demonstrated pseudomeningoceles from C2-C3 to C7-T1 with root avulsions of C5 and C6. He was subsequently indicated for a double Oberlin nerve transfer to restore elbow flexion. CONCLUSION In this case report, we present our technique and outcomes for a double Oberlin transfer with restoration of elbow flexion at 1-yr follow-up for a patient with traumatic brachial plexus injury. We believe that the double Oberlin transfer serves as a safe and effective method to restore elbow flexion in this patient population. Avulsion injury, Biceps brachii, Brachial plexus, Cervical spine, Elbow flexion, Nerve, Nerve transfer Transfer of the ulnar nerve fascicles to the biceps brachii has been described to restore elbow flexion following a C5-C6 avulsion injury.1 The brachialis muscle is a potent flexor of the elbow and restoration through nerve transfer has resulted in improved functional outcomes.2 When both the biceps and brachialis muscle functions’ are restored by a double Oberlin transfer of the median and ulnar nerve fascicles to the musculocutaneous nerve, patients have increased recovery of elbow flexion, as compared to single nerve transfers.2 There remains a paucity in the literature documenting technique and long-term outcomes for double Oberlin transfers. The purpose of this case report is to present our indications and technique for a double Oberlin transfer to restore elbow flexion following a traumatic C5-C6 avulsion injury. CLINICAL PRESENTATION Patient Information and Clinical Findings This is a 25-yr old, left-hand dominant male with no past medical history who presented as a referral to our institution following a motor vehicle accident. He underwent inpatient rehabilitation with physical and occupational therapy without symptomatic improvement. Since his injury, he has had significant left upper extremity weakness. Physical examination was notable for 0/5 deltoid, supraspinatus, infraspinatus, and biceps on the left, with decreased sensation to light touch over the lateral brachium, radial forearm and hand, and dorsal forearm and middle finger (Video, Supplemental Digital Content). Biceps and brachioradialis reflexes were absent. Diagnostic Assessment and Imaging Findings The patient's clinical examination was concerning for avulsion injury of the cervical roots. Other possible diagnoses included neuropathic disorders, infection-induced neuropathy, and syringomyelia. The patient's presentation aligned with a traumatic injury of the cervical roots given his muscular weakness, decreased sensory examination, and diminished reflexes. Magnetic resonance imaging and computed tomography myelogram demonstrated pseudomeningoceles from C2-3 to C7-T1 with root avulsions of C5 and C6, and partially C7 and C8 (Figures 1 and 2). Electromyelography findings were consistent with root avulsions of C5 and C6, and partially C7. The patient was indicated for double Oberlin transfer, 5 mo after his injury. FIGURE 1. View largeDownload slide Computed tomography myelogram of the cervical spine demonstrating an 8.8 mm × 23.6 mm pseudomeningocele at the level of C6. FIGURE 1. View largeDownload slide Computed tomography myelogram of the cervical spine demonstrating an 8.8 mm × 23.6 mm pseudomeningocele at the level of C6. FIGURE 2. View largeDownload slide Coronal view of computed tomography myelogram of the cervical spine depicting avulsion injury at the C5-C6 level on the left. FIGURE 2. View largeDownload slide Coronal view of computed tomography myelogram of the cervical spine depicting avulsion injury at the C5-C6 level on the left. Therapeutic Intervention The patient was brought to the operating room and prepped and draped in the usual sterile fashion. The left medial brachium was marked. The superior trunk of the brachial plexus was dissected, and the musculocutaneous nerve was identified. External neurolysis of the musculocutaneous, median, and ulnar nerves was performed. Direct nerve stimulation was utilized to confirm nerve identities. The median and ulnar nerves were stimulated individually with subsequent wrist and finger flexion, and tagged with rubber loops. Internal neurolysis of the median and ulnar nerves was performed. The epineurium was incised longitudinally, followed by an intrafascicular dissection, separating the individual fascicles of the nerves. Each fascicle was stimulated and those innervating wrist flexors were selected for nerve transfer; the fascicles innervating finger flexors were preserved. The musculocuteanous nerve branches to the biceps and the brachialis muscles were identified and sectioned approximately 1.5 cm from their insertion in the muscles. Under high power magnification, the neurorrhaphies were performed: fascicles controlling wrist flexion from the median and ulnar nerves were transferred to the musculocutaneous branches to the biceps and the brachialis muscles. There were no complications during or after the procedure. Follow-up and Outcomes The patient presented for follow-up (Table) with improvement in elbow flexion. As noted in Table, there was significant progress in the patient's range of motion and strength from the initial postoperative period to the 1-yr follow-up interval. The patient is currently satisfied with his progress and continues to perform range of motion and strength training exercises. Video, Supplemental Digital Content demonstrates the progression of the patient's strength flexing his elbow against resistance with a 10-pound dumbbell. TABLE. Tabulation of Follow-up Time and Interval Changes of the Patient's Elbow Flexion, Range of Motion, Sensation to Light Touch, and Reflexes Following the Double Oberlin Transfer. Follow-up time Elbow flexion Range of motion Sensation to light touch Reflexes 2 mo 0/5 Intact 2+ 5 m 3–/5 Intact 2+ 7 mo 4–/5 140° Intact 2+ 10 mo 4–/5 140° Intact 2+ 12 mo 4+/5 140° Intact 2+ Follow-up time Elbow flexion Range of motion Sensation to light touch Reflexes 2 mo 0/5 Intact 2+ 5 m 3–/5 Intact 2+ 7 mo 4–/5 140° Intact 2+ 10 mo 4–/5 140° Intact 2+ 12 mo 4+/5 140° Intact 2+ View Large TABLE. Tabulation of Follow-up Time and Interval Changes of the Patient's Elbow Flexion, Range of Motion, Sensation to Light Touch, and Reflexes Following the Double Oberlin Transfer. Follow-up time Elbow flexion Range of motion Sensation to light touch Reflexes 2 mo 0/5 Intact 2+ 5 m 3–/5 Intact 2+ 7 mo 4–/5 140° Intact 2+ 10 mo 4–/5 140° Intact 2+ 12 mo 4+/5 140° Intact 2+ Follow-up time Elbow flexion Range of motion Sensation to light touch Reflexes 2 mo 0/5 Intact 2+ 5 m 3–/5 Intact 2+ 7 mo 4–/5 140° Intact 2+ 10 mo 4–/5 140° Intact 2+ 12 mo 4+/5 140° Intact 2+ View Large Informed Consent Of note, informed consent for photography and videography was obtained from the patient prior to operative intervention. Institutional review board approval was not obtained as case reports do not meet requirements set forth by the Federal Policy for the Protection of Human Subjects in research. DISCUSSION Traumatic brachial plexus injuries have calamitous consequences. As nerve grafting is practically impossible following these injuries, nerve transfers have emerged as a treatment option. Nerve transfers utilize a donor fascicle to re-innervate a recipient denervated target muscle.3 There is limited data in the literature regarding technique and long-term outcomes of nerve function restoration using fascicular transfers following traumatic brachial plexus injuries. One modality of nerve transfer to restore elbow flexion in patients with C5-C6 root avulsion injury is the Oberlin transfer.1 Originally described in 1994, the procedure involves transferring the fascicles of the ulnar nerve to the biceps brachii muscle. Intraoperative nerve stimulation allows for identification of specific fascicles as neurological deficits may result from an improper transfer. The Oberlin transfer has also been reported following obstetric brachial plexus palsy with positive results in restoration of shoulder function.4 Most recently, nerve transfer procedures were found to be more effective in restoring functional outcomes, as compared to nerve grafting or combined techniques in brachial plexus injury.3 Oberlin's technique was expounded upon by Tung et al5 in the transfer of the ulnar nerve to the biceps and brachialis muscles. The authors followed 8 patients who underwent this transfer, finding positive results in the restoration of elbow flexion. Mackinnon et al2 reported on 6 patients who had a double Oberlin transfer, involving the ulnar and median nerves to the biceps and brachialis branches of the musculocutaneous nerve, respectively.6 At the 5.5-mo follow-up, patients had a mean elbow flexion of 4+. This study exhibited that the double nerve transfer may serve as a superior method of restoring elbow flexion following nerve injury. This was supported in a study of 10 patients, who at 6-mo follow-up had grade 4 elbow flexion following the double transfer.7 The limited number of studies still yields unanswered questions of comparative effectiveness to single transfers. Martins et al8 did not find significant differences between single and double transfers in the restoration or strength of elbow flexion. With additional studies, operative intervention will be elucidated to provide maximal patient outcomes. At 1-yr follow-up, our patient achieved 4+ elbow flexion, supporting the findings in the literature. One of the critical aspects of our intervention involved isolating specific fascicles prior to transfer. We isolated the fascicles of the median nerve involved in wrist flexion through neurostimulation. Our choice to neurotize these fascicles with the biceps is due to the proximity of the median nerve to the biceps. Correspondingly, the nerve to the brachialis sits more medially and its proximity to the ulnar nerve allowed for an ease of transfer. This combination provided an excellent restoration of function for this patient. Interestingly, the patient's reflexes returned at his 2-mo follow-up. Reflex assessment allows for delineation of motor neuron injury and function. There are limitations associated with reflex assessment as a modality to characterize reinnervation, as reflexes are more dominant in the flexor muscles of the upper limb and can be affected by sensory deficits that disrupt the reflex arc.9-11 Additionally, the responsive force of a reflex serves as a poor proxy for nerve injury, if collateral reinnervation has occurred.9 CONCLUSION In this case report, we present our technique and outcomes for a double Oberlin transfer with restoration of elbow flexion of a patient with traumatic brachial plexus injury. There are limited reports in the literature regarding outcomes and techniques of the double Oberlin nerve transfer, presenting a constraint to understanding the timeframes of progress in the postoperative period. This case report reveals our technique and portrays findings at pre- and postoperative timepoints to define these outcome measures. We believe that the double Oberlin transfer serves as a safe and effective method to restore elbow flexion in this patient population. Disclosures Dr Protopsaltis serves as a consultant for Medicrea, NuVasive, Globus, and Innovasis. Zimmer Biomet and the Cervical Spine Research Society provide research support to his institution. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. 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 C6 avulsion of the brachial plexus: anatomical study and report of four cases . J Hand Surg Am. 1994 ; 19A ( 2 ): 232 - 237 . Google Scholar CrossRef Search ADS 2. Mackinnon SE , Novak CB , Myckatyn TM , Tung TH . Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion . J Hand Surg Am. 2005 ; 30 ( 5 ): 978 - 985 . Google Scholar CrossRef Search ADS PubMed 3. Zarina S , Ali GGH , Ryan WF et al. Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques . J Neurosurg. 2015 ; 122 ( 1 ): 195 - 201 . Google Scholar CrossRef Search ADS PubMed 4. Noaman HH , Shiha AE , Bahm J . Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: Indications, and good and bad results . Microsurgery. 2004 ; 24 ( 3 ): 182 - 187 . Google Scholar CrossRef Search ADS PubMed 5. Tung TH , Novak CB , Mackinnon SE . Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries . J Neurosurg. 2003 ; 98 ( 2 ): 313 - 318 . Google Scholar CrossRef Search ADS PubMed 6. Rhode RS , Wolfe SW . Nerve transfers for adult traumatic brachial plexus palsy (Brachial plexus nerve transfer) . HSS J. 2007 ; 3 ( 1 ): 77 - 82 . Google Scholar CrossRef Search ADS PubMed 7. Liverneaux PA , Diaz LC , Beaulieu JY , Durand S , Oberlin C . Preliminary results of double nerve transfer to restore elbow flexion in upper type brachial plexus palsies . Plast Reconstr Surg. 2006 ; 117 ( 3 ): 915 - 919 . Google Scholar CrossRef Search ADS PubMed 8. Martins RS , Siqueira MG , Heise CO , Foroni L , Teixeira MJ . A prospective study comparing single and double fascicular transfer to restore elbow flexion after brachial plexus injury . Neurosurgery. 2013 ; 72 ( 5 ): 709 - 715 . Google Scholar CrossRef Search ADS PubMed 9. Mandeville RM , Brown JM , Sheean GL . A neurophysiological approach to nerve transfer to restore upper limb function in cervical spinal cord injury . Neurosurg Focus. 2017 ; 43 ( 1 ): E6 . Google Scholar CrossRef Search ADS PubMed 10. Brown JM , Kakulas BA . Restorative neurology: past, present, and future . Clin Neurol Neurosurg. 2012 ; 114 ( 5 ): 524 - 527 . Google Scholar CrossRef Search ADS PubMed 11. Minassian K , Hofstoetter U , Tansey K , Mayr W . Neuromodulation of lower limb motor control in restorative neurology . Clin Neurol Neurosurg. 2012 ; 114 ( 5 ): 489 - 497 . Google Scholar CrossRef Search ADS PubMed Supplemental digital content is available for this article at www.operativeneurosurgery-online.com. Supplemental Digital Content. Video. Double Oberlin nerve transfer clinical and surgical video. COMMENTS A well-documented with video nerve repair article. It is interesting that they chose to neurotize the biceps muscle branch with the median nerve fascicle instead of using the ulnar nerve fascicle which was used to neurotize the brachialis muscle branch; an argument can be made for neurotizing the brachialis muscle branch with a median nerve fascicle since this muscle does not supinate the forearm, which the biceps does when the arm is flexed at the elbow, which is an opposite action to forearm pronation which other median nerve branches mediate. I am surprised that the biceps and brachioradialis reflexes came back so soon after nerve repair, as muscle reflexes are usually the first to go after a nerve injury and the last to come back. Michel Kliot Chicago, Illinois This is a case report of a patient who underwent double fascicular nerve transfer to restore elbow flexion. The authors identified and isolated specific fascicles of the median nerve involved in wrist flexion through intraoperative stimulation, and utilized these specific fascicles for their nerve transfer. The authors have provided very good care to this patient with excellent clinical outcome. The video can serve as an excellent teaching material for students and residents learning this technique. The case report provided good documentation of the difficult surgical technique of the double Oberlin nerve transfer as well as the progression of physical exam findings during the postoperative period. Jason H. Huang Temple, Texas Copyright © 2018 by the Congress of Neurological Surgeons
Operative Neurosurgery – Oxford University Press
Published: Apr 2, 2018
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