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C OPYRIGHT 2013 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Contralateral C7 Nerve Transfer with Direct

Coaptation to Restore Lower Trunk Function After
Traumatic Brachial Plexus Avulsion
Shu-feng Wang, MD, Peng-cheng Li, MD, Yun-hao Xue, MD, Hon-wah Yiu, MD, Yu-Cheng Li, MD, and Hai-hua Wang, MD

Investigation performed at the Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, Republic of China

Background: Contralateral C7 nerve transfer to the median nerve has been used in an attempt to restore finger flexion in
patients with total brachial plexus avulsion injury. However, the results have not been satisfactory mainly because of the
requirement to use a long bridging nerve graft, which causes an extended nerve regeneration process and irreversible
muscle atrophy. A new procedure involving contralateral C7 nerve transfer via a modified prespinal route and direct
coaptation with the injured lower trunk is presented here.
Methods: Contralateral C7 nerve transfer via the modified prespinal route and direct coaptation with the injured lower
trunk was performed in seventy-five patients with total brachial plexus avulsion injury. Thirty-five required humeral
shortening osteotomy (3 to 4.5 cm) in order to accomplish the direct coaptation. The contralateral C7 nerve was also
transferred to the musculocutaneous nerve through the bridging medial antebrachial cutaneous nerve arising from the
lower trunk in forty-seven of the seventy-five patients. Recovery of finger, wrist, and elbow flexion was evaluated with use of
the modified British Medical Research Council muscle grading system.
Results: The mean follow-up period (and standard deviation) was 57 6 months (range, forty-eight to seventy-eight
months). Motor function with a grade of M31 or greater was attained in 60% of the patients for elbow flexion, 64% of the
patients for finger flexion, 53% of the patients for thumb flexion, and 72% of the patients for wrist flexion.
Conclusions: Contralateral C7 nerve transfer via a modified prespinal route and direct coaptation with the injured lower
trunk decreases the distance for nerve regeneration in patients with total brachial plexus avulsion injury. There was
satisfactory recovery of finger flexion and wrist flexion in this series. In addition, contralateral C7 nerve transfer was
successfully used to repair two different target nerves: the lower trunk and the musculocutaneous nerve.
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

S
urgical restoration of hand function, especially finger
flexion, is challenging in patients with total brachial
plexus avulsion injury. Contralateral C7 nerve transfer to
the median nerve via a long vascularized ulnar nerve graft was
considered a promising procedure in several studies1-6. How-
ever, the effectiveness of this surgical procedure in restoring
hand function remains controversial7,8.
One problem with the contralateral C7 nerve transfer is
the short length of the neurotizing nerve. A long bridging nerve
graft of >35 cm was used in the original report on this pro-
cedure3. Additionally, the regenerating axons of the contralat-
eral C7 nerve had to cross two neurorrhaphy sites to reach the
motor end plates of the forearm muscles, which may have
already become fibrotic. Following an anatomic study, we de-
signed a new procedure of contralateral C7 nerve transfer via a
modified prespinal route with direct coaptation of the con-
tralateral C7 nerve with the lower trunk to restore finger
flexion9. In order to present the long-term outcomes of this
modified procedure, we retrospectively reviewed the results in
seventy-five patients followed for a minimum of four years.

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. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this
work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, 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.

J Bone Joint Surg Am. 2013;95:821-7 d http://dx.doi.org/10.2106/JBJS.L.00039

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Materials and Methods
Patients
F rom May 2004 to December 2006, seventy-seven patients with total brachial
plexus avulsion injury underwent surgical exploration and contralateral C7
nerve transfer via the modified prespinal route and direct coaptation of the
contralateral C7 nerve with the lower trunk to restore finger flexion. All of the
procedures were performed by the senior author (S.-f.W.). Of the seventy-seven
patients evaluated, two were excluded: one because of a delay of longer than
twelve months between the injury and operation and the other because of
concomitant soft-tissue damage of the forearm. The remaining seventy-five
patients were evaluated after a minimum of four years of follow-up.
The preliminary diagnosis of complete brachial plexus injury was based on
a detailed history, meticulous physical examination, and findings on needle elec-
tromyography (EMG). Computed tomographic (CT) myelography was performed
on all patients. The criteria for the diagnosis of nerve-root preganglionic lesions
with CT myelography were the absence of a filling defect of one of the ventral and
dorsal rootlets (partial avulsion) or all of them (complete avulsion) on axial slices
and curved coronal reconstruction views, with or without the presence of a
pseudomeningocele. Sensory nerve action potentials and motor nerve conduction
were also examined before surgery. The presence of normal sensory nerve action
potentials and the absence of motor nerve conduction in the ulnar nerve indicate
preganglionic injury of the lower trunk when accompanied by loss of function on
physical examination and abnormal EMG findings in muscles innervated by the
same nerve. However, the final diagnosis of total brachial plexus avulsion injury
was based on the findings of surgical exploration.
The lower trunk injury was classified into two types according to the
intraoperative findings. Type I (preganglionic injury) indicated no postgangli-
onic lesions of the C8 and T1 nerve roots, and Type II indicated both pregan-
glionic and postganglionic injury. Type II was further classified as Type IIA
(lesions limited to the C8 and T1 nerve roots) and Type IIB (lesions extending
beyond the C8 and T1 nerve roots to the lower trunk, and even the medial cord).
Seventy patients were male and five were female, and the mean age (and
standard deviation) was 28 10 years old (range, ten to fifty-three years old).
The average interval from the injury to the operation was 4 2 months (range,
one to eleven months). The lower trunk injury was classified as Type I in forty-
one cases, Type IIA in twenty-two cases, and Type IIB in twelve cases.
Surgical Technique
With the patient in the supine position, the injured supraclavicular and in-
fraclavicular brachial plexus was exposed through a transverse incision about
2 cm above the clavicle and the deltopectoral groove approach, respectively. The
brachial plexus was completely exposed and carefully explored. Once the di-
agnosis of total brachial plexus avulsion injury was confirmed, the infracla-
vicular incision was extended distally to the midpoint of the upper arm. The
posterior division of the lower trunk was identified and divided at its origin.
The medial pectoral nerve and the medial brachial cutaneous nerve arising
from the medial cord were also identified and divided. The terminal branches of
the medial cord including the ulnar nerve, medial cord of the median nerve,
and the medial antebrachial cutaneous nerve were identified and dissected
distally up to the midlevel of the upper arm. The lateral cord of the median
nerve and the lateral cord were also completely dissected. The musculocuta-
neous nerve was divided at its origin. This subsequently freed the lower trunk,
allowing it to be fully mobilized proximally.
A similar supraclavicular transverse incision was made on the contra-
lateral side, the contralateral C7 nerve root was identified, and its anterior and
posterior divisions were dissected as far distally as possible; it was divided at the
junction between divisions and cords. Then the contralateral C7 nerve root was
dissected proximally to the neuroforamina. The details of the modified prespinal
9
route have been previously reported . It is illustrated schematically in Figures 1-A
and 1-B. The length of the contralateral C7 nerve root was measured
After the contralateral C7 nerve had been transferred to the interval
between the carotid sheath and sternocleidomastoid muscle on the injured side,
the medial antebrachial cutaneous nerve was divided at the appropriate level of
the injured upper arm and transferred to the musculocutaneous nerve. The
infraclavicular incision was closed first. Then the injured upper extremity was
positioned with the shoulder in 0 of adduction and 0 to 10 of anterior

Fig. 1-A Fig. 1-B

Schematic illustration of the contralateral C7 nerve transfer via the modified prespinal route. The contralateral C7 nerve was transected at the distal end
of the divisions and dissected up to the neuroforamina. The tip of a right-angle forceps was passed underneath the scalenus anterior muscle and the
vertebral artery, and then it penetrated the longus colli muscle to the interval space between the carotid sheath and the esophagus on the normal side.
The tunnel was expanded sufficiently. One end of a plastic tube with a diameter of about 5 mm was drawn to initially pass through this tunnel. Another end
of the plastic tube, which passed through the retro-esophageal space created by blunt dissection under direct vision, was drawn to the interval space
between the carotid sheath and the esophagus on the injured side. The contralateral C7 nerve root was wrapped in the plastic tube and sutured in place.
Then, the contralateral C7 nerve root was passed to the injured side with use of the plastic tube as a guide. 1 = contralateral C7 nerve root, 2 = anterior
scalene muscle, 3 = sternocleidomastoid muscle, 4 = carotid sheath, 5 = vertebral artery and vein, 6 = longus colli muscle, 7 = esophagus, 8 = thyroid
gland, 9 = trachea, 10 = plastic tube with diameter of 5 mm used to guide the contralateral C7 nerve pass through the prespinal route, 11 = right-angle
forceps, and 12 = middle scalene muscle.
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TABLE I Muscle Motor Function Restoration after Contralateral C7 Nerve Transfer Via the Modified Prespinal Route and Direct
Coaptation with the Lower Trunk in Seventy-five Patients*

Finger Flexion (no. [%]) Thumb Flexion (no. [%]) Wrist Flexion (no. [%])
NHS HS Total NHS HS Total NHS HS Total
Result (N = 40) (N = 35) (N = 75) (N = 40) (N = 35) (N = 75) (N = 40) (N = 35) (N = 75)

Excellent (M4 to M52) 16 (40) 15 (43) 31 (41) 8 (20) 8 (23) 16 (21) 22 (55) 18 (51) 40 (53)
Good (M31 or M42) 9 (23) 8 (23) 17 (23) 11 (28) 13 (37) 24 (32) 6 (15) 8 (23) 14 (19)
Fair (M21 to M3) 3 (8) 5 (14) 8 (11) 6 (15) 4 (11) 10 (13) 2 (5) 4 (11) 6 (8)
Poor (M0 to M2) 12 (30) 7 (20) 19 (25) 15 (38) 10 (29) 25 (33) 10 (25) 5 (14) 15 (20)
x2 = 1.581, p = 0.664 x2 = 1.239, p = 0.744 x2 = 2.698, p = 0.441

*NHS = no humeral shortening, and HS = humeral shortening.

flexion, the elbow in 90 of flexion, and the forearm placed on the abdomen.
This position was maintained until the operation was finished and a pre-
fabricated brace was applied. The freed lower trunk was pulled proximally and
preferably divided just distal to where the posterior division of the lower trunk
arises, and direct coaptation of the contralateral C7 nerve with the injured lower
trunk was performed with use of 8-0 nylon (Fig. 2). When the nerves did not
reach and the defect was <5 cm in adults or <3 cm in children, the humerus was
shortened to allow direct coaptation. The humeral shaft was approached by
retracting the brachial biceps muscle medially and splitting the brachialis
muscle. The osteotomy was done with an oscillating saw just distal to the
insertion of the deltoid muscle, and the amount of humeral shortening was
tailored to the defect between the transferred contralateral C7 nerve and the
injured lower trunk. A six-hole Locking Compression Plate (LCP) (Synthes,
West Chester, Pennsylvania) was applied to the medial aspect of the humerus. A
prefabricated brace was used to hold the patients head in the neutral position
and the injured upper extremity in the described position above (the shoulder
in 0 of adduction and 0 to 10 of anterior flexion, the elbow in 90 of flexion,
and the forearm on the abdomen).
served. Patients were instructed to notice the recovery of finger flexion when the
contralateral arm was forcefully adducted.
The modified British Medical Research Council (MRC) muscle grading
10
system was used to evaluate motor function every six months after the patients
regained finger flexion. The strength of finger flexion was tested with the wrist
extended 20 to 30. Muscle strength was graded as poor (M0 to M2), fair (M21
to M3), good (M31 or M42), or excellent (M4 to M52). The MRC sensory
scale was used for sensory assessment on the palmar aspect of each digit, the
11
thenar eminence, and the hypothenar eminence of the affected hand .
Donor site morbidity was monitored regularly after the surgery. Muscle
strength of the triceps and the extensor digitorum communis was evaluated with
use of the MRC grading scale. Muscle strength was evaluated at one week, three
months, and twelve months postoperatively. Grip strength was assessed with the
E-LINK machine (model E-LINK CX4; Biometrics, Newport, United Kingdom)
at one week, three months, and twelve months postoperatively. Static two-point

Reconstruction Methods
All patients in this series underwent direct coaptation of the transferred
contralateral C7 nerve with the injured lower trunk. The phrenic nerve was
transferred to the musculocutaneous nerve in the first twenty-eight patients.
In the remaining forty-seven patients, the contralateral C7 nerve was
transferred to the musculocutaneous nerve through the bridging medial
antebrachial cutaneous nerve. The spinal accessory nerve was transferred to
the suprascapular nerve in fifty patients; in the other twenty-five cases, the
suprascapular nerve was not repaired because of coexisting paralysis of the
accessory nerve, distal avulsion of the suprascapular nerve, or nerve transfer
at the second stage. In order to restore the sensation of the hand, five patients
underwent an additional procedure with two or three branches of the su-
praclavicular cutaneous nerve transferred to the lateral cords contribution
to the median nerve (group B), while the remaining seventy patients un-
Fig. 2
derwent only contralateral C7 nerve transfer to repair the injured lower
Schematic illustration of the direct coaptation of the contralateral C7 nerve
trunk (group A).
The humerus was shortened by 3 to 4.5 cm (average, 4.2 0.5 cm) in with the lower trunk (performed in all of the patients in this series) and the
thirty-five patients, including fifteen (37%) of the forty-one with Type-I transfer of the contralateral C7 nerve to the musculocutaneous nerve
(preganglionic) injury, eleven (50%) of the twenty-two with Type-IIA (limited through the bridging medial antebrachial cutaneous nerve (performed in
preganglionic and postganglionic) injury, and nine (75%) of the twelve with some patients). 1 = contralateral C7 nerve root, 2 = lower trunk, 3 = medial
Type-IIB (extensive preganglionic and postganglionic) injury.
antebrachial cutaneous nerve, 4 = ulnar nerve, 5 = median nerve, 6 =
lateral cord of median nerve, 7 = medial cord of median nerve, 8 = mus-
Evaluation
The advancement of the Tinel sign along the median and ulnar nerves on the culocutaneous nerve, 9 = lateral cord, 10 = posterior cord, 11 = radial
injured side was checked at the follow-up visits. When it reached the midlevel of nerve, 12 = axillary nerve, 13 = posterior division of lower trunk, 14 = C8
the forearm, EMG was done every three months until finger flexion was ob- nerve root, and 15 = T1 nerve root.
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TABLE II Results of Elbow Flexion Restoration in the Forty-seven Patients with the Musculocutaneous Nerve Neurotized
by the Contralateral C7 Nerve Via the Bridging Medial Antebrachial Cutaneous Nerve

Group without Humeral Shortening Group with Humeral Shortening All Patients
Result (N = 28) (no. [%]) (N = 19) (no. [%]) (N = 47) (no. [%])

Excellent (M4 to M52) 13 (46) 8 (42) 21 (45)

Good (M31 or M42) 5 (18) 2 (11) 7 (15)
Fair (M21 to M3) 4 (14) 4 (21) 8 (17)
Poor (M0 to M2) 6 (21) 5 (26) 11 (23)
x2 = 0.876; p = 0.831

discrimination of the donor-side digits was measured one week postoperatively.
Complications related to the prespinal route procedures were monitored.
Statistical Methods
Statistical analysis was performed with use of SPSS 13.0 statistical software
(SPSS, Chicago, Illinois). A chi-square test was used to compare motor power
recovery of the elbow, wrist flexion, and digital flexion between patients with
and those without shortening of the humerus. A Fisher exact test was used to
compare hand sensory recovery between groups A and B.
Source of Funding
We did not receive any outside funding or grants in support of our research or
preparation of this work.
Results
T he average length of the contralateral C7 nerve was 6.5
0.8 cm (range, 4.8 to 8 cm). The mean follow-up period
was 57 6 months (range, forty-eight to seventy-eight
months). Nascent EMG potentials in the flexor digitorum
profundus and superficialis were noted at an average of 12 4
months (range, six to twenty-two months) postoperatively in
seventy-one patients, all of whom reported noticeable finger
flexion eight to twenty-eight months (average, 15 5 months)
postoperatively. The remaining four patients had no finger
flexion recovery demonstrated by either physical examination
or EMG at the latest follow-up visit.
At the latest follow-up visit, 64% of the patients had a
good or excellent result for finger flexion (see Appendix);
53%, for thumb flexion; and 72%, for wrist flexion (Table I).
There was no significant difference between the group with
humeral shortening and the one without humeral shortening
with regard to finger flexion (x2 = 1.58, p > 0.6), thumb
flexion (x2 = 1.24, p > 0.7), or wrist flexion (x2 = 2.7, p > 0.4)
(Table I).
Forty-seven patients had simultaneous contralateral C7
nerve transfer to the musculocutaneous nerve (Table II).
Good-to-excellent elbow flexion was achieved in 60% of the
cases. Nineteen (40%) of the forty-seven had shortening hu-
meral osteotomy, but there was no significant difference in
elbow flexion recovery between this group and the one without
humeral shortening (x2 = 0.9, p > 0.8).
The phrenic nerve was transferred to the musculocuta-
neous nerve in twenty-eight patients. Elbow flexion was graded
as M4 to M52 in twenty-one of these cases, M31 or M42 in
two cases, and M0 to M3 in five cases. A good-to-excellent
result was achieved in 82% of these patients.
In the fifty patients who had the spinal accessory nerve
transferred to the suprascapular nerve, the average shoulder
abduction was 45 23.
The overall results for sensory recovery are summarized
in Table III.

TABLE III Hand Sensory Recovery After Contralateral C7 Nerve Transfer in Seventy-five Patients*

Little, Ring,
and Long Fingers
(no.) Index Finger (no.) Thumb (no.) Hypothenar (no.) Thenar (no.)
Group A Group B Group A Group B Group A Group B Group A Group B Group A Group B
Result (N = 70) (N = 5) (N = 70) (N = 5) (N = 70) (N = 5) (N = 70) (N = 5) (N = 70) (N = 5)

S3 to S4 26 3 3 2 0 3 26 3 0 2
S2 36 2 24 3 6 2 36 2 22 3
S1 or S0 8 0 43 0 64 0 8 0 48 0
(Fisher) (Fisher) (Fisher) (Fisher) (Fisher)
x2 = 1.232, x2 = 8.899, x2 = 23.705, x2 = 1.167, x2 = 14.831,
p = 0.802 p = 0.006 p = 0.00 p = 0.802 p = 0.00

*Group A = direct coaptation of the contralateral C7 nerve with the lower trunk, and Group B = with additional supraclavicular cutaneous nerve
transfer to the lateral head of the median nerve.
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TABLE IV Changes in Muscle Strength and Grip Strength of Donor Upper Extremity After Contralateral C7 Nerve Transfer
in Seventy-five Patients*

1 Wk Postoperatively (no. [%]) 3 Mo Postoperatively (no. [%]) 12 Mo Postoperatively (no. [%])

Finger MPJ extension

M5 32 (43) 64 (85) 70 (93)
M4 27 (36) 9 (12) 4 (5)
M3 15 (20) 1 (1) 1 (1)
M2-M0 1 (1) 1 (1) 0 (0)
Elbow extension
M5 23 (31) 61 (81) 73 (97)
M4 45 (60) 13 (17) 2 (3)
M3 6 (8) 1 (1) 0 (0)
M2-0 1 (1) 0 (0) 0 (0)
GFDP
<10% 27 (36) 56 (75) 68 (91)
;10% 24 (32) 9 (12) 4 (5)
;20% 7 (9) 7 (9) 3 (4)
;30% 7 (9) 3 (4) 0 (0)
;40% 6 (8) 0 (0) 0 (0)
50% 4 (5) 0 (0) 0 (0)

*MPJ = metacarpophalangeal joint, and GFDP = grip force decreased percentage, calculated by subtracting the postoperative grip force from the
preoperative grip force, dividing by the preoperative grip force, and multiplying by 100%.

The muscle strength of the triceps and the extensor
digitorum communis and the grip strength on the donor side
after the contralateral C7 nerve transection are summarized in
Table IV. In one patient, the muscle strength of the extensor
digitorum communis decreased to M0 and that of the triceps
decreased to M2 postoperatively, but they recovered to M3 and
M4, respectively, twelve months postoperatively. Most patients
complained of numbness over the thumb and index and long
fingers on the donor side postoperatively. However, objective
static two-point discrimination was within 3 to 5 mm one week
postoperatively. Numbness disappeared postoperatively within
three months in 71% (fifty-three) of the seventy-five patients
and within four to six months in the remainder.
There was no injury to the esophagus or pharynx. Five
patients complained of tingling over the fingers on the donor
side while swallowing, but this gradually disappeared within
ten days.
Discussion
nerve graft between the transferred contralateral C7 nerve and
the median nerve is a major concern. In order to shorten the
intercalated nerve graft used in contralateral C7 nerve transfer,
Yu and colleagues12 designed a modified procedure consisting
of direct coaptation of the anterior and posterior divisions of
the transferred contralateral C7 nerve with the median nerve
and ulnar nerve, respectively. However, this required shorten-
ing of the affected upper arm by 13 to 20 cm in the three
patients with total brachial plexus avulsion injury in their
study. The patients regained only partial hand grasp function.
Additionally, both the patients and the surgeons were con-
cerned over the cosmetic appearance after the surgery.
Direct coaptation of the contralateral C7 nerve to the
injured lower trunk with use of the technique that we described
here can sometimes be performed without humeral shorten-
ing. The key steps required to achieve a tension-free primary
nerve coaptation without major shortening of the humerus are
as follows. First, we maximize the available length of the con-
tralateral C7 nerve: the average length in this series was 6.5 cm.

N erve transfer is currently one of the methods of choice for

the management of total brachial plexus avulsion injury.
Shoulder and elbow function can usually be satisfactorily re-
stored by transfer of the spinal accessory nerve and intercostal
nerves. However, there is no good method with which to re-
store hand function, such as prehension.
Contralateral C7 nerve transfer can theoretically provide
sufficient myelinated axons to transfer to the median nerve to
restore finger flexion function in patients with total brachial
plexus avulsion injury. However, the use of a long intercalated
Second, the contralateral C7 nerve is transferred to the recip-
ient site via a modified prespinal route, which is the shortest
way of transferring the nerve to the injured side. Third, the
injured lower trunk is maximally freed and mobilized. Addi-
tionally, a limited humeral shortening osteotomy was used in
thirty-five patients to allow the contralateral C7 nerve to reach
the lower trunk without requiring a nerve graft to bridge the
gap. As most of the patients with a Type-IIB injury and half of
the patients with a Type-IIA injury needed a shortening hu-
meral osteotomy, the extent of the damage to the lower trunk is
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one of the key factors in determining whether a shortening
humeral osteotomy is needed. Shortening the humerus more
than approximately 12% to 14% of its original length will cause
cosmetic concerns and also result in malfunction of the triceps
and biceps muscles13. Therefore, we recommend that the hu-
merus be shortened by <5 cm in adults and <3 cm in children.
Otherwise, a bridging nerve graft is indicated.
Immobilizing the injured upper extremity in a specific
position helped to achieve a tension-free direct coaptation
between the contralateral C7 nerve and the lower trunk. There
is a concern that there will be tension across the neurorrhaphy
site once the brace is removed and the shoulder is moved
through a range of motion postoperatively. The nerves are
intrinsically elastic structures that are always under some
tension and subjected to various degrees of stretching (i.e.,
with joint movement)14. Sunderland et al.15 showed evidence
that a nerve repair could withstand stretching once it was
healed. We believe that the position of the shoulder (0 of
adduction and 0 to 10 of anterior flexion) and the elbow
(90 of flexion) designed for direct nerve coaptation in this
study is reasonable.
In this series, the muscle strength of the brachial biceps
reached M31 or greater in 60% (twenty-eight) of the forty-
seven patients after the contralateral C7 nerve was transferred
to the musculocutaneous nerve. Although encouraging results
with regard to elbow flexion restoration have been achieved, we
think that there is still room for improvementfor example,
by transferring an additional motor branch, such as the branch
to the pectoralis major that arises from the distal end of the
anterior division of the middle trunk, to the musculocutaneous
nerve via a bridging nerve graft.
It is difficult to compare our results with those of studies
of hemi-contralateral C7 nerve transfer to the median nerve.
Waikakul et al.3 transferred the anterior division of the con-
tralateral C7 nerve to the median nerve using a vascularized
pedicle of the ulnar nerve as a graft in ninety-six cases, all of
which were followed for more than three years. Muscle power
of M3 or greater was restored to the wrist flexors in 29% of the
cases and to the finger flexors in 21%. Recently, Sammer et al.16
reported their results after using the same method as Waikakul
et al. in fifteen cases, who were followed for more than twenty-
seven months. Three of the fifteen patients demonstrated EMG
evidence of reinnervation, but none developed composite grip
strength of M3 or greater. The best result following the tradi-
tional methods of contralateral C7 nerve transfer to the median
nerve was reported by Gu17, who transferred the entire con-
tralateral C7 nerve to neurotize the median nerve in fourteen
patients. After an average of two years of follow-up, the muscle
power of the finger flexors recovered to M4 in three patients,
M3 in four patients, and M2 to M0 in seven patients. Gu at-
tributed these noteworthy results to the fact that the entire
contralateral C7 nerve was used in the procedure. However, M3
muscle strength of the finger flexors is insufficient for the hand
grasp function.
At the time of the latest follow-up in our series, muscle
strength for finger, thumb, and wrist flexion was M31 or
C O N T R A L AT E R A L C7 N E R V E T R A N S F E R W I T H D I R E C T C O A P TAT I O N
A F T E R T R AU M AT I C B R A C H I A L P L E X U S AV U L S I O N
greater in 64%, 53%, and 72% of the patients, respectively.
These outcomes were remarkably superior to those in reports
by previous authors3,10,16,17. The superior results achieved in
this series are likely due to the shortened nerve regeneration
distance between the transferred contralateral C7 nerve and
the forearm target muscles as well as having only one neu-
rorrhaphy site. Statistical analysis indicated that the recovery
of protective sensation over the thumb and index finger in
group B was significantly better than that in group A. There-
fore, we recommended that the supraclavicular cutaneous
nerve transfer to the lateral cords contribution to the median
nerve be performed in conjunction with direct coaptation of
the contralateral C7 nerve to the lower trunk.
In this series, the transient decreases in the muscle
strength of the triceps and/or the extensor digitorum com-
munis on the donor side after the complete contralateral C7
nerve transection were consistent with those reported in the
literature5-7 with the exception of one patient who had muscle
strength of M2 and M0 for the triceps and the extensor
digitorum communis, respectively. However, none of the
patients in our study reported any permanent functional
deficit on the donor side one year postoperatively. This
demonstrates that the contralateral C7 nerve can be safely
transected at the distal level. After contralateral C7 nerve
transection, only the posterior division of the lower trunk
remained to compensate for the function of metacarpopha-
langeal joint extension18. Hence, even a minor injury to it can
cause loss of extension of that joint. The key way to prevent
this from happening is to protect the posterior division of the
lower trunk to avoid any iatrogenic injury during the process
of dissecting the posterior division of the contralateral C7
nerve.
Appendix
Figures showing an illustrative case are available with
the online version of this article as a data supplement at
jbjs.org. n
NOTE: The authors thank Jiyao Zou, MD, Assistant Professor, Division of Reconstructive and
Plastic Surgery, University of Arizona, and Dov Asher Brandis, MS-III, University of Arizona College
of Medicine, for their editorial assistance.
Shu-feng Wang, MD
Peng-cheng Li, MD
Yun-hao Xue, MD
Yu-Cheng Li, MD
Hai-hua Wang, MD
Department of Hand Surgery,
Beijing Jishuitan Hospital,
No. 31 East Street of Xinjiekou, West District,
Beijing 100035, Republic of China.
E-mail address for S.-f. Wang: wangshufeng1964@yahoo.com.cn
Hon-wah Yiu, MD
Department of Orthopaedics, North District Hospital,
No. 1 Po kin Road, Fanling,
New Territories HKSAR, Hong Kong
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