Journal of Orthopaedic Surgery 2012;20(1):66-70

Anterior deltopectoral approach for axillary nerve neurotisation

Department of Orthopedics, Hand and Reconstructive Microsurgery, Apollo Specialty Hospitals, KK Nagar, Madurai, India

J Terrence Jose Jerome

ABSTRACT Purpose. To report outcome of axillary nerve neurotisation for brachial plexus injury through the anterior deltopectoral approach. Methods. Nine men aged 20 to 52 (mean, 27.8) years with brachial plexus injury underwent axillary nerve neurotisation through the anterior deltopectoral approach. Three of the patients had complete avulsion of C5-T1 nerve roots. The remaining 6 patients had brachial plexus injury of C5-C6 nerve roots, with associated subluxation of the glenohumeral joint, atrophy of the supraspinatus, deltoid and elbow flexors. They had no active shoulder abduction, external rotation, and elbow flexion. The pectoralis major and minor were cut and/or retracted to expose the underlying infraclavicular plexus. The axillary nerve was identified with respect to the available donor nerves (long head of triceps branch, thoracodorsal nerve, and medial pectoral nerve). In addition to the axillary nerve neurotisation, each patient had a spinal accessory nerve transferred to the

suprascapular nerve for better shoulder animation. Results. Patients were followed up for 24 to 30 (mean, 26) months. In the 3 patients with C5-T1 nerve root injuries, the mean active abduction and external rotation were 63 and 20, respectively, whereas the mean abduction strength was M3 (motion against gravity). In the 6 patients with C5-C6 nerve root injuries, the mean active abduction and external rotation were 133 and 65, respectively, whereas the strength of the deltoids and triceps was M5 (normal) in all. In 4 patients with the pectoralis major cut and repaired, the muscle regained normal strength. Conclusion. The anterior deltopectoral approach enabled easy access to all available donor nerves for axillary nerve neurotisation and achieved good outcomes.
Key words: axilla; brachial plexus neuropathies; nerve transfer

INTRODUCTION Shoulder abduction is important for upper limb functions, as more distal functions depend on a

Address correspondence and reprint requests to: Dr J Terrence Jose Jerome, Department of Orthopedics, Hand and Reconstructive Microsurgery, Apollo Specialty Hospitals, KK Nagar, Madurai 625 020, India. E-mail: terrencejose@gmail.com

Vol. 20 No. 1, April 2012

Anterior deltopectoral approach for axillary nerve neurotisation

67

stable shoulder.16 Reconstruction of both axillary and suprascapular nerves can improve shoulder function and glenohumeral joint stability.610 A number of approaches to axillary nerve neurotisation for brachial plexus injuries have been reported, but all have limitations.1113 We report outcomes of axillary nerve neurotisation for brachial plexus injury through the anterior deltopectoral approach. MATERIALS AND METHODS In March 2009, 9 consecutive men aged 20 to 52 (mean, 27.8) years with brachial plexus injury of the right (n=6) and left (n=3) shoulders after falling from a bike underwent axillary nerve neurotisation through the anterior deltopectoral approach. The power of the muscle involved was assessed using the Medical Research Council (British) system. Radiographs, computed tomographic myelography, and/or magnetic resonance imaging of the cervical spine, shoulder, and chest were obtained. The preganglionic injury and nerve root avulsion were confirmed electrophysiologically and clinically (deafferentation pain, Horner syndrome, absent Tinel sign, and weak rhomboid and serratus muscles). Three of the patients had complete avulsion of C5-T1 nerve roots, without any associated chest wall or lung injury. The remaining 6 patients had brachial plexus injury of C5-C6 nerve roots, with associated subluxation of the glenohumeral joint, atrophy of the supraspinatus, deltoid and elbow flexors. They had no active shoulder abduction, external rotation, and elbow flexion. All 9 patients had at least M4 power (motion against resistance) in the triceps. The patient was placed in a supine position, with a sandbag beneath the affected extremity. Under general anaesthesia, the supraclavicular part of the plexus was exposed through a transverse incision 2 cm above the clavicle at the root of the neck. The extent of injury was confirmed by electrical stimulation. The spinal accessory nerve was identified along the superior border of the trapezius and transferred to the suprascapular nerve preserving its proximal branch. For C5-T1 nerve root injuries, the intercostal nerve was transferred to the axillary and musculocutaneous nerves through the anterior deltopectoral approach. For C5-C6 nerve root injuries, the patients underwent the Oberlin procedure (transferring ulnar nerve fascicle to the biceps branch of the musculocutaneous nerve) for elbow flexion through the distal extension of the deltopectoral approach, and the long head of the triceps branch was transferred to the axillary nerve (Fig.).

(a)

Axillary nerve Radial nerve

LHTB*

(b)

Figure (a) The locations of the axillary nerve (lateral), radial nerve (middle), and long head of triceps branch (LHTB) [medial] at the posterior cord level. (b) The orientation of the medial pectoral nerve (branch from medial cord), thoracodorsal nerves, and the LHTB (asterisk) with the axillary nerve.

Postoperatively, the patients were put on broad arm sling for 3 weeks. Electrical stimulation was started at week 6. The range of movement and muscle power were regularly assessed. RESULTS The mean interval from injury to surgery was 4.3 (range, 26) months. Patients were followed up for 24 to 30 (mean, 26) months (Table 1). Shoulder control and palpable contractions were noted at postoperative month 2. In the 3 patients with C5T1 nerve root injuries, the mean active abduction

68

JTJ Jerome Table 1 Patient characteristics and outcomes

Journal of Orthopaedic Surgery

Patient Sex/age Side Interval Injury Donor FollowPostop Postop Postop no. (years) involved from area nerve* up shoulder shoulder external injury to (months) abduction range of rotation surgery motion (months) 1 2 3 4 5 6 7 8 9 M/23 M/30 M/52 M/31 M/22 M/25 M/26 M/21 M/20 Left Right Right Left Right Left Right Right Right 2 6 4 4 5 5 3 5 3 C5-T1 C5-T1 C5-C6 C5-T1 C5-C6 C5-C6 C5-C6 C5-C6 C5-C6 IC IC LHTB IC LHTB LHTB LHTB LHTB LHTB 25 24 30 28 24 26 27 26 24 M3 M3 M5 M3 M5 M5 M5 M5 M5 60 70 130 60 140 130 140 130 130 M3 M3 M5 M3 M5 M5 M5 M5 M5

Additional nerve transfers*

IC to MCN, SAN to SSN IC to MCN, SAN to SSN SAN to SSN, Oberlin transfer IC to MCN, SAN to SSN SAN to SSN, Oberlin transfer SAN to SSN, Oberlin transfer SAN to SSN, Oberlin transfer SAN to SSN, Oberlin transfer SAN to SSN, Oberlin transfer

* IC denotes intercostal nerve, LHTB long head of triceps branch, MCN musculocutaneous nerve, SAN spinal accessory nerve, SSN suprascapular nerve, and Oberlin transfer transferring ulnar nerve fascicle to biceps branch of musculocutaneous nerve M3 denotes motion against gravity, M4 motion against resistance, M5 normal strength

and external rotation were 63 and 20, respectively, whereas the mean abduction strength was M3 (motion against gravity). In the 6 patients with C5-C6 nerve root injuries, the mean active abduction and external rotation were 133 and 65, respectively, whereas the strength of the deltoids and triceps was M5 (normal) in all. The outcome of transferring the long head of triceps branch was superior to transferring the intercostal nerve to the axillary nerve. In 4 patients with the pectoralis major cut and repaired, the muscle regained normal strength. DISCUSSION The posterior, lateral, and medial cords of the brachial plexus receive their respective names from their spatial orientation to the second part of the axillary artery. Nonetheless, there are considerable variations in the orientation and interconnections of the cords to each other and to the major vessels. A few specific nerves emerging from the posterior, lateral, and medial cords can be used as donors for neurotisation in brachial plexus injuries.14,15 For axillary nerve neurotisation through the anterior deltopectoral approach, the key landmarks are the cephalic vein (as a guide to the deltopectoral groove), the clavipectoral fascia (covering the infraclavicular brachial plexus as it exits under the tendon of the pectoralis minor), the lateral cord, and the axillary artery. The pectoralis major and pectoralis minor are cut and/or retracted to view the infraclavicular plexus. If exposure is difficult, these muscles are cut and taken up with tie sutures

for final approximation. The lateral cord and the axillary artery are swept medially to enable access to the posterior cord and axillary nerve. The axillary nerve is neurotised, depending on the length of the donor nerves. The axillary nerve exits the posterior cord at the level of the lower border of the pectoralis minor, curves backward and passes through the quadrangular space together with the posterior circumflex humeral artery,1316 where it divides into anterior and posterior branches. The axillary nerve is located high in the axilla, posterior to the axillary artery, lateral to the radial nerve, and anterior to the subscapularis. The long head of triceps branch (first branch of the radial nerve) is posterior and medial to the radial nerve at this region. These 3 nerves course more or less parallel in their exit at this level of approach. In this region, the axillary nerve is lateral, the radial nerve is in the middle, and the long head of triceps branch is medial (Fig.). The long head of triceps branch is transferred to the axillary nerve. For C5-C6 brachial plexus injuries, the anterior deltopectoral approach enables easy access to various donor nerves. The long head of triceps branch can be transferred to thoracodorsal or mediopectoral nerves. The median nerve fascicles, ulnar nerve fascicles, thoracodorsal and mediopectoral nerves can be transferred to the axillary nerve. The axillary nerve is one of 2 terminal branches of the posterior cord of the brachial plexus. It contains fibres from C5 and C6 ventral rami. The anterior branch innervates the anterior deltoid and the largest posterior branch innervates the teres minor and deltoid. The supraspinatus and deltoid are equally

Vol. 20 No. 1, April 2012

Anterior deltopectoral approach for axillary nerve neurotisation

69

Table 2 Comparison of studies involving axillary nerve neurotisation using the triceps branch for brachial plexus injuries of C5-C6 Studies Lurje,23 1948 Colbert and Mackinnon,2 2008 Vekris et al,21 2010 Bertelli et al,13 2007 Bertelli and Ghizoni,8 2004 Leechavengvongs et al,11 2003 Our study No. of patients 1 1 5 3 7 7 6 Approach Anterior Posterior Posterior Axillary recess Posterior Posterior Anterior deltopectoral Donor nerve Unnamed branch Medial head of triceps branch Long head of triceps branch Long/medial head of triceps branches Long head of triceps branch Long head of triceps branch Long head of triceps branch Mean Deltoid abduction strength* 35 110 45 92 124 133 Good M4- to M4 M4 External rotation Satisfactory 3010 -

M3+ to M4 3 (-10 to 30) M4 M4 M5 M5

* M3 denotes motion against gravity, M4 motion against resistance, M5 normal strength

responsible for producing torque about the shoulder joint in the functional planes of motion, whereas the deltoid is capable of initiating elevation in the plane of the scapula. The infraspinatus is a powerful external rotator, followed by the teres minor and the posterior deltoid.15,16 There are different approaches to neurotise the axillary nerve. The interval between the lateral and the long heads of the triceps is located in the posterior approach11 at the level of the triangular space to expose the radial nerve, nerves to the long head and lateral head of the triceps. Through the posterior approach, excessive retraction of the deltoid is required and may result in injury to the posterior branch of the axillary nerve and limited arm abduction.17,18 Therefore, caution is necessary. The disadvantages of the posterior approach are difficulty in dissecting the teres minor branch, change of position following the brachial plexus exploration and the suprascapular neurotisation procedures, separate incision, and extended operating time. The entire axillary and suprascapular nerves are explored through a sabre-cut incision12 starting anteriorly near the axillary fold and continuing along the deltopectoral groove over the clavicle to the quadrilateral space posteriorly. The success of this extensive procedure depends on a meticulous surgical technique and secure reattachment of muscles. The axillary recess approach13 exposes the axillary nerve in a triangle bounded by the latissimus dorsi tendon, posterior circumflex humeral artery, and subscapular artery. The anterior and middle deltoid branch is the most laterally located, curving around the humerus, whereas the teres minor branch is close to the long head of the triceps. Although the axillary nerve can be exposed by the axillary approach, its proximal portion is difficult to dissect through this approach. Thus, the

anterior deltopectoral approach is preferable for the proximal dissection of the axillary nerve. In our study, the outcome of transferring the intercostal nerve to the axillary nerve was only moderate. Intercostal nerves contain 500 to 700 nerve fibres. In complete brachial plexus injury, the results of transferring the intercostal nerve vary widely, depending on the level of the intercostal nerve transection, the number of transferred nerves, the level of the nerve anastomosis, and the use of nerve grafts. In 4 patients with complete brachial plexus palsy, shoulder control to a maximum of 30 abduction was achieved using the intercostal, phrenic, and spinal accessory nerves as donors.19 The mean improvement was 10 in abduction when concomitant connection (double nerve transfers) of the suprascapular nerve to the phrenic nerve and the axillary nerve to the cranial nerve XI.19 The overall and useful recovery rates were 63% and 33%, respectively, for the axillary nerve,20 whereas the shoulder abduction was <40 with M3-/M3 motor power.21 None of the above studies provided any results on external rotation recovery. In our study, 3 patients achieved a mean abduction of 65 with M3 grade of external rotation. Shoulder re-animation was achieved with suprascapular nerve neurotisation, because supraspinatus function (rotator cuff) is important in the shoulder arc of motion and stabilisation along with axillary nerve neurotisation. Functional improvement of the shoulder is better in patients with successful re-innervation of the biceps. Although transferring the intercostal nerve to the axillary nerve does not confer muscle strength, speed, range of motion, and endurance,22 it enables better shoulder abduction and external rotation. In C5-C6 nerve root injuries, concomitant neurotisation of the suprascapular nerve and the axillary nerve enabled better outcomes in shoulder

70

JTJ Jerome

Journal of Orthopaedic Surgery

abduction and external rotation.110 Transferring the long head of triceps branch to the axillary nerve is superior, because the nerve is close to the target muscle. It increases the likelihood of reinnervation under voluntary control and is not tied to antagonist co-contractions owing to aberrant axonal growth. Also, it significantly improves the external rotation

when combined with simultaneous transfer of the spinal accessory nerve to the suprascapular nerve. Transferring the long head of triceps branch to the axillary nerve through different approaches has been reported (Table 2).2,8,11,13,21,23 In our study, the anterior deltopectoral approach enabled good exposure and access to various donor nerves within close vicinity.

REFERENCES
1. Terzis JK, Barmpitsioti A. Axillary nerve reconstruction in 176 posttraumatic plexopathy patients. Plast Reconstr Surg 2010;125:23347. 2. Colbert SH, Mackinnon SE. Nerve transfers for brachial plexus reconstruction. Hand Clin 2008;24:34161. 3. Van Ouwerkerk WJ, Uitdehaag BM, Strijers RL, Frans N, Holl K, Fellner FA, et al. Accessory nerve to suprascapular nerve transfer to restore shoulder exorotation in otherwise spontaneously recovered obstetric brachial plexus lesions. Neurosurgery 2006;59:85869. 4. Terzis JK, Kostas I. Suprascapular nerve reconstruction in 118 cases of adult posttraumatic brachial plexus. Plast Reconstr Surg 2006;117:61329. 5. Terzis JK, Kostas I, Soucacos PN. Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients. Microsurgery 2006;26:31624. 6. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Malungpaishrope K. Combined nerve transfers for C5 and C6 brachial plexus avulsion injury. J Hand Surg Am 2006;31:1839. 7. Malessy MJ, de Ruiter GC, de Boer KS, Thomeer RT. Evaluation of suprascapular nerve neurotization after nerve graft or transfer in the treatment of brachial plexus traction lesions. J Neurosurg 2004;101:37789. 8. Bertelli JA, Ghizoni MF. Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve. J Hand Surg Am 2004;29:1319. 9. Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg Am 2001;26:30314. 10. Bahm J, Noaman H, Becker M. The dorsal approach to the suprascapular nerve in neuromuscular reanimation for obstetric brachial plexus lesions. Plast Reconstr Surg 2005;115:2404. 11. Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg Am 2003;28:6338. 12. Ochiai N, Nagano A, Mikami Y, Yamamoto S. Full exposure of the axillary and suprascapular nerves. J Bone Joint Surg Br 1997;79:5323. 13. Bertelli JA, Kechele PR, Santos MA, Duarte H, Ghizoni MF. Axillary nerve repair by triceps motor branch transfer through an axillary access: anatomical basis and clinical results. J Neurosurg 2007;107:3707. 14. Perry J. Biomechanics and functional anatomy of the shoulder. In: Chapman MW, editor. Chapmans orthopaedic surgery. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001:20632077. 15. Wolock B, Millesi H. Brachial plexus: applied anatomy and operative exposure. In: Gilberman RH, editor. Operative nerve repair and reconstruction. Philadelphia: JB Lippincott; 1991:1255. 16. Broome R. Practical anatomy, clinical assessment and surgical exposure. In: Broome RS, editor. The brachial plexus. New York: Churchill Livingstone; 1977:9. 17. Ball CM, Steger T, Galatz LM, Yamaguchi K. The posterior branch of the axillary nerve: an anatomic study. J Bone Joint Surg Am 2003;85:1497501. 18. Hong TC, Kumar VP, Nather A. The posterior neuromuscular compartment of the deltoid. Plast Reconstr Surg 2005;115:1660 4. 19. Chuang DC, Lee GW, Hashem F, Wei FC. Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg 1995;96:1228. 20. Samardzic M, Rasulic L, Grujicic D, Milicic B. Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 2000;46:93103. 21. Vekris MD, Beris AE, Pafilas D, Lykissas MG, Xenakis TA, Soucacos PN. Shoulder reanimation in posttraumatic brachial plexus paralysis. Injury 2010;41:3128. 22. Moiyadi AV, Devi BI, Nair KP. Brachial plexus injuries: outcome following neurotization with intercostal nerve. J Neurosurg 2007;107:30813. 23. Lurje A. Concerning surgical treatment of traumatic injury to the upper division of the brachial plexus (Erbs type). Ann Surg 1948;127:31726.