Neurosurg Focus 16 (5):Article 5, 2004, Click here to return to Table of Contents

Nerve transfers for severe brachial plexus injuries: a review

RAJIV MIDHA, M.D., MSC., F.R.C.S.(C)

Division of Neurosurgery, Department of Surgery, Sunnybrook and Women’s College Health Sciences
Centre, University of Toronto, Ontario, Canada

Nerve transfer procedures are increasingly performed for repair of severe brachial plexus injury (BPI), in which the
proximal spinal nerve roots have been avulsed from the spinal cord. The procedure essentially involves the coaption
of a proximal foreign nerve to the distal denervated nerve to reinnervate the latter by the donated axons. Cortical plas-
ticity appears to play an important physiological role in the functional recovery of the reinnervated muscles. The author
describes the general principles governing the successful use of nerve transfers. One major goal of this literature review
is to provide a comprehensive survey on the numerous intra- and extraplexal nerves that have been used in transfer
procedures to repair the brachial plexus. Thus, an emphasis on clinical outcomes is provided throughout. The second
major goal is to discuss the role of candidate nerves for transfers in the surgical management of the common severe
brachial plexus problems encountered clinically. It is hoped that this review will provide the treating surgeon with an
updated list, indications, and expected outcomes involving nerve transfer operations for severe BPIs.

KEY WORDS • brachial plexus injury • nerve transfer • neurotization •

accessory nerve • C-7 spinal nerve • intercostal nerve • medial pectoral nerve

Nerve transfers (so-called neurotization) involve the re- The anatomical and physiological principles that under-
pair of a distal denervated nerve element by using a prox- lie nerve transfers are relatively straightforward. Because
imal foreign nerve as the donor of neurons and their axons motor recovery has been the main goal, the choice of a
to reinnervate the distal targets. The concept is to sacrifice donor nerve element with a reasonable amount of motor
the function of a lesser-valued donor muscle to revive fibers is required.71 The loss of the muscle due to dener-
function in the recipient nerve and muscle that will under- vation when transferring the donor nerve must not repre-
go reinnervation.71 The first report of neurotization in an sent loss of important or critical function.55 Obviously, the
attempt to restore injured plexus function was published value of the neuromuscular element to be reinnervated
by Tuttle100 in 1913. A review of the historical precedents must greatly exceed the utility of the sacrificed one. An
as well as the anatomical basis and rationale for nerve excellent compromise is achieved if some function of the
transfers in brachial plexus surgery was most clearly pre- donor muscle can be retained, by using only a portion of
sented 20 years ago by Narakas.70 Since then, nerve trans- the nerve as the donor, which has been exemplified by the
fers have become increasingly popular and used for the use of half of the hypoglossal nerve (thus, not completely
repair of BPIs, especially in cases in which the proximal denervating ipsilateral tongue) for transfer to the facial
motor source of the denervated element is absent due to nerve for reanimation of the face.6,22,28,83
avulsion from the spinal cord.88 Increasingly advocated as There are several important principles to adopt to max-
well is the use of nerve transfers in cases in which the imize outcome in nerve transfers, the first of which is to
proximal motor source is available but the distance be- reinnervate the recipient nerve as close to the target mus-
tween removal and reimplantation is so long that the out- cle as possible.72 An outstanding example of the latter is
come would be poor;30,31 a nerve transfer into the dener- the transfer of an ulnar nerve fascicle directly to the biceps
vated distal nerve stump close to the motor end organ branch of the musculocutanoeus structure in close prox-
would then restore function, which otherwise would not be imity to its entry into the muscle.74 The second principle
possible.72 The use of nerve transfers has been a major involves performing a direct repair, without intervening
advance in the field of brachial plexus nerve reconstructive
surgery, with many different ingenious transfers associat- grafts; this tactic seems to be associated with improved
ed with improving results, as reported and reviewed re- outcomes, as reported convincingly after intercostal–mus-
cently.11,43, 64,88,98 culocutaneous transfers.45,58,69,76,103 The third principle is to
use combinations of similarly behaving neuromuscular
units, maximized when agonistic donor and recipient are
Abbreviations used in this paper: BPI = brachial plexus injury; chosen, as cortical readaptation is the physiological basis
MRC = Medical Research Council. for functional recovery.56,59 This may also be the physio-

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logical underpinning that explains why intraplexal (for ex- the integrity of sensory roots but do not reflect the status
ample, medial pectoral–musculocutaneous) nerve donors of the motor (ventral) roots, which can be measured using
may yield superior results compared with extraplexal (for motor evoked potential and/or neck muscle potential mon-
example, intercostal–musculocutaneous) nerves.79 The itoring.15,73 The intraoperative electrical tests and operative
last principle, not so different from that in all nerve sur- findings are used in concert with the preoperative clinical,
gery (assuming that the nerve is irreparably damaged electromyography,9 and imaging16 findings to determine
and incapable of spontaneous functional regeneration)66 the extent of injury and presence of nerve root avulsion
in which prolonging axotomy and target denervation is as- and to guide operative decisions concerning the suitable
sociated with progressively poorer outcomes,30,31 is to per- nerve reconstructive procedure.
form the transfer surgery as early as possible to maximize The goal in the management of upper (C-5 and C-6)
outcomes.80,81 nerve root paralysis is complete repair. When the upper
two roots are avulsed from the spinal cord, the only repair
option is neurotization by a nerve transfer. The nature of
NERVE TRANSFER TECHNIQUES the reparative strategy is then dictated by the number of
root avulsions, including the consideration of whether C-
Surgical Approach 7 is also avulsed. On the other hand, even in complete
The surgical management of patients with a severe BPI severe palsy, the C-5 spinal nerve may be singularly
is first to determine preoperatively whether most or all the spared, thus allowing it to be used as the source of axons
nerve roots are truly avulsed.65 The second aspect of sur- for a plexus–plexus repair to distal elements.34,47 There are
gery is to perform nerve repair, which, in the severe cases some cases in which the proximal root stump may not be
with avulsion, incorporates appropriate nerve transfers to suitable for grafting. A very proximal intraforaminal dis-
reanimate the extremity.88 Surgical exploration therefore section of the nerve roots is invaluable for assessing the
warrants exposure of the entire supra- and infraclavicular nerve anatomically,48 and combined with the examination
plexus, with an appropriately made incision, as well as of frozen section of the very proximal stump to assess the
marking of incisions that will allow exposure of donor fascicular pattern and absence of ganglion cells, has been
nerves that may need to be transferred (Fig. 1). The upper useful in decision making. Other authors have assessed
extremity, extending to the anterior and lateral chest wall, the degree of myelin staining to predict the quality of the
and both legs being targeted for donor sural grafts, should stump;61 however, in uncertain circumstances, a nerve
be appropriately prepared. transfer is preferred to using a proximal stump of ques-
After complete and thorough exposure of the plexus, tionable integrity. The combinations for repair therefore
including intraforaminal dissection and external neuroly- include intraplexal grafts alone obtained from a single
sis of the nerve-in-continuity, intraoperative electrodiag- functioning root, intraplexal grafts, and selective transfers
nostic studies should be conducted.66 First, motor evoked (the usual scenario) or transfers alone for the devastating
stimulation is used to determine which roots are conduct- cases in which all nerve roots are avulsed (Fig. 1). The
ing by observing the distal muscles contraction, occasion- nerve transfer options available will be discussed further.
ally augmented by needle-based electromyography. Nerve
action potentials are measured across the neuroma or Accessory Nerve Transfer
in clinically nonfunctioning roots, with large fast-con-
ducting (preganglionic) nerve action potentials seen when In the earliest report of a nerve transfer by Tuttle100 in
the nerve root is avulsed.49,51,66,97 Somatosensory evoked 1913, the author mentioned using the accessory nerve (as
potentials produced in the contralateral cortex help gauge well as elements of the cervical plexus) as the donor.
Accessory (11th cranial) nerve transfers for otherwise
irreparable BPIs, however, were popularized independent-
ly in the early 1980s by Allieu, et al.,3,4 and others.5,71 In
the early series, a diverse number of recipient targets were
chosen, and, depending on the distal nerve element, inter-
posed grafts were often needed. Based on cadaveric stud-
ies,46 an improved appreciation of the extracranial acces-
sory nerve’s anatomy has led to the use of more distal
dissection of the nerve close to trapezius muscle inser-
tional points, where the very distal nerve is divided prior
to its transfer.41 This preserves some trapezius innerva-
tion and allows a direct transfer to the adjacent supras-
capular nerve, without the need for an interpositional graft
(Fig. 2).
For restoration of dynamic shoulder function, both the
suprascapular and axillary nerves have been chosen as tar-
gets. Whereas the former can be repaired directly by end-
Fig. 1. Photograph showing incisions to expose various plexal to-end suture with the distal accessory nerve, the latter
and extraplexal donor and recipient nerve elements. This patient requires planning an interposed nerve graft. The authors
suffered clinically complete Erb palsy and avulsion of C-5 and C- of recent series have confirmed Alnot’s bias5 that the
6 spinal nerves; he underwent surgery after a delayed referral (the suprascapular, compared with axillary, nerve is a superior
same patient is represented in Figs. 6 and 7). target for accessory nerve transfer, with generally good

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Nerve transfers for brachial plexus injuries

fers, Merrell, et al.,64 concluded that best results for shoul-

der abduction were achieved by conducting accessory
nerve–suprascapular nerve transfers.
The other major target for accessory nerve transfer has
been the musculocutaneous nerve. In recent series the re-
sults for elbow flexion were shown to be very good, with
an MRC Grade 3 or better outcome in 65%,79 72%,80
72.5%,89 and 83%103 of patients in respective studies. In
the analysis of factors predicting outcome, the most im-
portant negative predictor was increased duration between
injury and surgery, whereas the need for a lengthier graft
also negatively influenced results.80,103 Although a meta-
analysis of the literature has indicated that intercostal
nerve donors are best for musculocutaneous nerve as the
recipient nerve,64 only Waikakul, et al.,103 directly com-
pared two extraplexal donors, reporting that the accessory
nerve achieved superior outcomes for elbow flexion com-
pared with intercostal nerves.

Intercostal Nerve Transfers

The concept for intercostal nerve transfers to repair
BPIs can be credited according to Narakas,70 to Yeoman,
working with Seddon, and Seddon;84 this early experience
is reviewed in the latter’s classic textbook. Although Sed-
don reported the use of the second–fourth intercostal
nerve transfer to the distal musculocutaneous nerve, Do-
Fig. 2. Intraoperative photographs. A: A transverse incision 1 lenc24 performed multiple intercostal transfers to several
cm superior to left clavicle allows simultaneous exposure of the additional distal elements of the plexus, including axillary,
suprascapular nerve (Penrose drain), just after its origin from the median, and radial nerves. He used sural and ulnar nerves
upper trunk and accessory nerve (vessel loop) distal to branches of as interposed grafts and reported considerable success,
the latter (arrow) to trapezius muscle (asterisk). B: Direct trans- although few details were provided.24 Subsequently, sev-
fer of the distal accessory to the suprascapular nerve with micro- eral other surgeons independently adopted this technique
surgical repair.
for reinnervation of the musculocutaneous nerve but with
variable success.45,67,68,71,85–87
Friedman and colleagues29 used standardized tech-
results reported in the majority of patients (Fig. 3).19,40,77 niques involving transfer of three intercostal nerves
A detailed analysis of glenohumeral function in pa- (third–fifth) to the distal musculocutaneous nerve, without
tients with long-term follow up who underwent accessory interposed grafts, which led to more consistent results,
nerve–suprascapular nerve transfer, however, has demon- approaching MRC Grade 3 or better function in approxi-
strated rather poor true abduction (Malessy, personal com- mately 50% of the patients. These authors provided the
munication), supporting the observation that shoulder first detailed evidence of independent (that is, without
function will be optimized if both suprascapular and axil- synkinetic respiratory movements) biceps function over
lary nerves and their muscles are reinnervated.79 In a time, hinting at cortical plasticity, a concept that has
recent metaanalysis of the literature related to nerve trans- subsequently been validated by electrophysiological and
functional brain mapping/imaging studies.56,59,60,62 Indeed,
it has been suggested that functional return depends on
cortical readaptation and that failures have been construed
as lack of such adaptation;56 this hypothesis, however,
requires validation.
More recently investigators studying intercostal–mus-
culocutaneous nerve transfer have demonstrated signifi-
cantly improved results, (MRC grade
3 elbow flexion
in 64–88% of reported cases).26,45,58,69,76,88,103 Intercostal
nerve transfers to musculocutaneous nerves in infants
with obstetrical brachial plexus palsy produced reliably
good outcomes (MRC grade
4 elbow flexion in nearly
85% of patients).44 The authors of these recent series have
stressed the importance of dissecting the intercostal nerves
Fig. 3. Photograph obtained at 3-year follow-up visit. This well distally along the rib to allow their transfer easily to
patient experienced excellent outcome after undergoing an acces- the axilla and direct repair without graft placement, as has
sory–suprascapular nerve transfer to treat clinically complete Erb been demonstrated in anatomical studies (Fig. 4).7
palsy and C5–7 nerve avulsions. The group from Duke University has also reported, in

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 R. Midha

available as an intraplexal donor for reinnervating the dis-

tal upper truncal or its divisional outflow.47,50,95 Such a
transfer can be associated with very good outcomes in
terms of recipient elements,47,95,96 with little risk of func-
tional loss secondary to harvesting the C-7 spinal nerve.36
Considerable caution, however, is required if significant
lower plexus lesions coexist36 because the muscles inner-
vated by C-7, which would be normally redundantly sup-
plied by C-8 (and T-1) spinal nerves, will not be present.50
The use of the contralateral C-7 spinal nerve as donor
for transfer has corroborated the redundancy of the C-7
nerve, confirming the safety of sacrificing this struc-
ture.18,95 Other than mild loss of triceps function and clin-
ically inconsequential loss of the triceps reflex, the pro−
cedure appears to be safe as far as motor loss is
concerned.18,95 Sensory abnormalities, however, are com-
mon after C-7 sacrifice and may be permanent in 5% of
cases.92 Moreover, neuropathic pain may be evoked tem-
porarily in a minority of patients,2 and in rare cases per-
manent motor deficits in wrist extension may develop.90
Selective use of anterior or posterior portions of the con-
tralateral C-7 nerve, aided by intraoperative electrophysi-
ological testing,42 may make the procedure safer, further-
ing the specificity of the reinnervated element to which it
is transferred.95
Chuang and colleagues20 first reported the use of the
contralateral C-7 spinal nerve obtained from the normal,
noninjured side, where the first stage involved the repair
to the C-7 nerve and placement of long sural nerve grafts
across the chest. In their initial series of 15 patients, eight
were candidates for the second stage (~ 1 year later) con-
sisting of innervation of free muscle grafts placed in the
affected paralyzed limbs. They reported modest results of
nonindependent movement in the paralyzed limb in this
Fig. 4. Intraoperative photograph depicting a curvilinear inci- pioneering effort, attesting to both the possibility but also
sion lateral to nipple (upper-left region in photograph) and just
anterior to anterior axillary line; this allows exposure of the left limitations of the technique. Authors of subsequent series
third–fifth intercostal nerves for transfer to the musculocutaneous in adolescents and adults reported the results of contralat-
nerve in the axilla. eral C-7 transfer by grafting cross-chest sural or vascular-
ized ulnar nerve directly to recipient infraclavicular plex-
al nerve elements.18,35,37,95,96,102,107 In the largest reported
selected cases, intercostal neurotization of nerve to a free series, the long-term functional outcome was very good,
muscle graft that successfully achieved elbow flexion.29 but the authors only reported data obtained in 20 of 82
Although Waikakul, et al.,103 have reported superior re- patients in their initial study and 30 of 224 patients who
sults when using accessory nerve, compared with inter- underwent the procedure.35,37 Additionally, synchronous
costal transfers for elbow flexion, the authors of a large movement of the unaffected arm during attempts to move
series of 37 adolescents and adults who underwent place- the reinnervated limb have been a repeated concern.35 The
ment of gracilis muscle grafts for elbow flexion found that best results associated with using the contralateral C-7
intercostal neurotization of nerve to free muscle was a bet- nerve in 98 adolescents and adults with complete avulsion
ter choice than using the accessory nerve.21 In severe injuries were published by Waikakul and colleagues;102
obstetrical brachial plexus palsy, a gracilis free muscle they noted that when the median nerve was the recipient,
transfer (innervated by the accessory nerve) has been good sensory function was achieved in approximately half
shown to restore elbow flexion.10 Doi and colleagues23 the adolescents, and some also exhibited forearm muscle
have reported a two-stage (“double”) free muscle transfer recovery. In a carefully reported 3-year follow-up study,
procedure that successfully restored prehensile function in Songcharoen and associates90 reported median nerve mo-
a few very severe cases. tor recovery (MRC Grade 3 or 4) in approximately 20%
Unilateral intercostal nerve transfers do not disturb res- of their patients, whereas in another 20% MRC Grade 2
piratory function,32 but they should not be performed if the outcome in wrist flexion was observed. Sensory domain
phrenic nerve is dysfunctional or used on the ipsilateral outcome was somewhat better, especially in adolescents,
side as a donor for transfer.55 with 50% exhibiting useful sensory restoration in the
median nerve distribution. In study of adults with BPIs,
Ipsilateral and Contralateral C-7 Spinal Nerve Transfer
Terzis and coworkers96 reported that the mean MRC grade
In some cases of Erb palsy,27 in which both C-5 and C- was 3 (antigravity) in their series. One group transferred
6 nerves are avulsed, the C-7 spinal nerve is intact and C-7 spinal nerves via vascularized ulnar nerve graft, to the

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Nerve transfers for brachial plexus injuries

lateral cord contribution to median nerve; they reported a however, noted that in their hands, a portion of the medi-
100% success rate with good sensory recovery.26 an nerve was a more reliable donor for achieving elbow
One of the main criticisms of this transfer technique flexion recovery than the phrenic nerve.43 When the
remains the long graft (and hence regeneration) distance. phrenic nerve is sacrificed, one important issue is the re-
The possibility of a prespinal retropharyngeal route for sulting respiratory compromise, in which decrease in vital
graft placement has been proposed.63 Nevertheless, the capacity has been measured to be a mean of approximate-
technique remains limited because of the rather modest ly 10%.55 Although not clinically important in the majori-
motor recovery, the fact that synchronous movement of ty of situations, this degree of respiratory loss will produce
the unaffected side is required, and the small but real risk symptoms in higher-demand situations and may be se-
that the donor site may be injured and a functional deficit verely detrimental to infants and children who develop
results.90,92 Perhaps a targeted approach to obtaining me- respiratory infections. This factor essentially precludes the
dian nerve distribution sensory recovery is warranted,26 use of the phrenic nerve as a donor in infants undergoing
although similar outcomes may be possible with a less nerve reconstruction for obstetric palsy. Moreover, it also
cumbersome transfer from the lower intercostal nerves to implies that the intercostal nerves should not be used as
the sensory (lateral cord) head of the median nerve.24 donors for transfer when phrenic nerve function is absent
preoperatively or when the phrenic nerve is transferred.
Cervical Plexus
The use of the anterior branches of the cervical plexus Medial Pectoral Nerves
(C-3 and C-4) for transfer to the distal elements usually The pectoralis major muscle has dual input from the
supplied by (the avulsed) upper spinal nerves was first medial and lateral pectoral nerves, arising from the medi-
advocated by Brunelli and Monini.14 Based on cadaveric al and lateral cords, respectively. Because C-5 and C-6
studies in which they observed present (but variable- avulsion interrupts the lateral cord supply, the muscle re-
sized) discernible sensory and motor branches, the authors mains innervated (and strong) as long a significant injury
reported modest results after selective transfer of motor is not incurred to the C-7 and C-8 elements. Although
branches to musculocutaneous, suprascapular, and axil- popularized recently for upper plexal injuries,13 using the
lary nerves and sensory branches to the median nerve. medial pectoral nerve as a donor for transfer was pre-
Earlier efforts to transfer the entire cervical plexus ele- viously considered and infrequently used, as indicated
ments to the avulsed C-5 and C-6 roots failed, likely be- by Narakas70 for adults and Gilbert33 for obstetric palsy.
cause of the great disparity between the number of axons Brandt and Mackinnon13 directed the medial pectoral to
in the donor cervical plexus elements and the recipient the musculocutaneous nerve, with the additional innova-
elements.14 Recently, however, Yamada and colleagues106 tion of turning the lateral antebrachial cutaneous nerve
performed surgery in three cases in which they transferred (the cutaneous derivative of the musculocutaneous nerve)
the anterior primary rami of C-3 and C-4, just distal to into the biceps muscle to avoid loss of motor axons into
phrenic nerve, via sural nerve grafts directly to the upper the cutaneous distribution. A resurgence of interest in this
trunk; the patients had suffered C-5 and C-6 avulsion transfer has been associated with reports of useful out-
injuries, and the authors reported good results postopera- comes (defined as MRC grade
3) in elbow flexion in
tively in shoulder girdle and biceps muscles, as well as approximately 84% of patients.78 Excellent results in ob-
improved sensation. In a larger series, they obtained even stetric palsy too have been published, with success in 68%
better results in cases involving upper plexus palsy and, of cases.12 Others have criticized the use of this transfer
surprisingly, in cases involving complete flail arm.105 Oth- strategy in obstetric palsy because of loss of arm adduc-
er investigators have been unable to validate these remark- tion, which can be useful for the infant, toddler, and child
able results, demonstrating more modest success when to hold objects against the trunk,59 especially because the
using the motor components (which are unfortunately intercostal transfer yields such favorable results in this set-
quite limited after phrenic nerve supply14) to branches ting.44 The results of various series vary, however, and
of the upper trunk when both C-5 and C-6 nerves are Samardzic, et al.,79 have noted that medial pectoral nerve
avulsed.25,47,50 transfers were associated with significantly improved out-
comes in elbow flexion compared with intercostal and ac-
Phrenic Nerve
cessory nerve transfers. These authors have also been one
Unlike the cervical plexus, which contains a variable of the few groups to demonstrate remarkably good results
number of motor fibers,14 the phrenic nerve contains a after axillary nerve transfer; they observed useful results
large number of pure motor axons that allow the possibil- in greater than 80% of patients.78
ity of entire or partial transfer with success.101 In the early With the increasing interest in the medial pectoral nerve
use of the phrenic nerve for transfer, investigators noted as a donor, the anatomy of the pectoral nerve complex has
good outcomes.17,101 Subsequently, transfers involving the been more clearly defined.8,39 The traditional concept of
phrenic nerve as the neurotizer have been performed with separate lateral and medial pectoral nerves innervating the
considerable success. 17,19,38,43,101,107 In one study of 12 pa- pectoralis minor and major muscles as discrete nerves has
tients, phrenic nerve transfer to musculocutaneous, supra- been replaced; in fact, these nerves run toward the pec-
scapular, or axillary nerves was successful in 75% of toralis minor and major muscles, exhibiting considerable
cases.88 Particularly, the transfer to the musculocutaneous branching and intermingling. Not infrequently, a plexus
nerve has been an excellent tactic, with 11 of 12 patients forms where branches from the medial and lateral pectoral
exhibiting better than antigravity function (MRC Grade 3) nerves, destined for the pectoralis major, merge and then
and 58% exhibited MRC Grade 4 function.55 One group, final branches move toward the muscle (Fig. 5A).8,39 Be-

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 R. Midha

cause only one or, at times, two of these terminal branch- eral authors.1,43,52,54,74,94 Most impressive have been the re-
es to the pectoralis are required (and quite distally) for the sults reported by Sungpet and associates94 who used a sin-
transfer, the practical implication is that some pectoralis gle ulnar nerve fascicle directed to the biceps muscle; they
major muscle supply can be preserved and a direct repair observed MRC Grade 3 or better outcome in 34 of 36 pa-
without intervening graft can be performed to the muscu- tients. They also noted that time to reinnervation began as
locutaneous nerve in the distal axilla (Fig. 5B).72 Caution early as 3.3 months postoperatively and that hand and
needs to be exercised if C-7 and C8 nerves are signifi- ulnar function, assessed using a series of tests and func-
cantly injured; in this case, the pectoralis major muscle tional tools, was not compromised during a long-term fol-
will be quite weak preoperatively, and this finding is a low-up period. The key aspect of the procedure is to rein-
contraindication to medial pectoral transfer. A similar so- nervate the biceps branch close to its motor entry into the
phisticated appreciation of the innervated anatomy to the muscle.93
biceps and brachialis muscles93 has prompted evolution in The authors of a recent report indicated that elbow flex-
transfer techniques so that both the biceps and brachialis ion function will be further augmented (especially in cases
muscles discretely become reinnervated.99 of delayed surgery) by also concomitantly reinnervating
brachialis muscle by using a graft from the medial pector-
Distal Interplexal Transfer al nerve.99 Another alternative to the ulnar fascicle is a fas-
An exciting development in neurotization has been the cicle of the adjacent median nerve to transfer to biceps
transfer of portions of functioning distal plexal elements muscle nerve; good results have been reported in 64%43 to
for the direct reinnervation of nerve branches going to 80% of patients.91
critical muscles that are paralyzed.72 This era really began An emerging transfer technique is the direct repair of
recently with anatomical studies of the fascicular patterns the anterior branch of the axillary nerve; in this procedure,
and their application in several patients in whom a single the nerve to the long head of triceps in the posterior arm is
redundant ulnar nerve fascicle was transferred to biceps used (Fig. 7).53,104 The anatomy involved in this transfer
branches in the medial arm to restore elbow flexion (Fig. operation104 as well as good-to-excellent results achieved
6).74 These initial excellent results were validated by sev- in seven cases,53 especially when combined with accesso-
ry–suprascapular nerve transfer, may herald improved dy-
namic shoulder function than previously possible with the
flail shoulder after C-5 and C-6 avulsions.53 Indeed, au-
thors of the most recent series have demonstrated the ben-
efit of several targeted transfers in patients with plexus
avulsions.11

Other Transfers
Although the hypoglossal nerve has been an excellent
donor for transfer to the facial nerve,75,82 it has an extreme-
ly limited value for neurotization of brachial plexus ele-
ments.28,57

Fig. 6. Intraoperative photograph. For transfer of an ulnar nerve

Fig. 5. Intraoperative photographs. A: Pectoral nerves and fascicle to biceps nerve in the medial arm, the common epineuri-
their complex (upper spear) as well as the musculocutaneous nerve um of the ulnar nerve is opened under microscopic magnification;
(lower spear) in the axilla are exposed. B: Distal division of the four to five fascicles and a redundant fascicle (vessel loop) are cho-
pectoral nerve close to muscle and proximal division of the mus- sen to transfer directly to the adjacent biceps nerve branch of mus-
culocutaneous nerve allow direct end-to-end repair. culocutaneous nerve (both on tissue background).

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Nerve transfers for brachial plexus injuries

plexus elements can be directed to the sensory aspect of

the median nerve. These transfer strategies are certainly
appropriate for cases in which a complete flail arm is ex-
hibited with all five spinal nerve roots avulsed; however,
it is most important in this case to ensure that the C-5
spinal nerve is in fact avulsed and not ruptured extra-
foraminally.48 Not to perform intraplexal repair of an intact
C-5 spinal nerve to its distal outflow would be a disservice
because of the relatively few extraplexal transfer possibil-
ities available. In uncertain cases, the repair from C-5 to
distal elements can be augmented by the transfer of acces-
sory and intercostal nerves.47
Although the aforementioned strategy is appropriate for
the pan-plexus injury, treatment of isolated Erb palsy is
different. If C-5 and C-6 are avulsed while C-7 is clearly
intact, intraplexal graft repairs from C-7 may be consid-
ered to reinnervate the shoulder abductors and elbow flex-
ors.47 Alternatively, directed discrete transfers should be
performed; based on the most recent literature, this seems
to be a favored approach. A combination of the following
should be performed: distal accessory to suprascapular;
ulnar nerve fascicle to biceps nerve (perhaps augmented
by a portion of medial pectoral nerve via graft to bra-
chialis nerve); and long head of triceps nerve to the ante-
rior portion of the axillary nerve.11

References
1. Al-Qattan MM: Oberlin’s ulnar nerve transfer to the biceps
nerve in Erb’s birth palsy. Plast Reconstr Surg 109:405–407,
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102. Waikakul S, Orapin S, Vanadurongwan V: Clinical results of anterior rami of C-3 and C-4 to the upper trunk of the brachial
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Nerve transfer to deltoid muscle using the nerve to the long Manuscript received March 15, 2004.
head of the triceps, part I: an anatomic feasibility study. J Accepted in final form April 2, 2004.
Hand Surg Am 28:628–632, 2003 Address reprint requests to: Rajiv Midha, M.D., Division of
105. Yamada S, Lonser RR, Iacono RP, et al: Bypass coaptation Neurosurgery, Department of Surgery, Sunnybrook and Women’s
procedures for cervical nerve root avulsion. Neurosurgery College Health Sciences Centre, University of Toronto, 2075
38:1145–1152, 1996 Bayview Avenue, Toronto, ON M4N 3M5, Canada. email:
106. Yamada S, Peterson GW, Soloniuk DS, et al: Coaptation of the [email protected].

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