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The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis

  • Clinical Article - Neurosurgical Techniques
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Abstract

Background

Controversy exists surrounding the use of the phrenic nerve for transfer in severe brachial plexus injuries. The objectives of this study are: (1) to present the experience of the authors using the phrenic nerve in a single institution; and (2) to thoroughly review the existing literature to date.

Methods

Adult patients with C5-D1 and C5-C8 lesions and a phrenic nerve transfer were retrospectively included. Patients with follow-up shorter than 18 months were excluded. The MRC muscle strength grading system was used to rate the outcome. Clinical repercussions relating to sectioning of the phrenic nerve were studied. An intense rehabilitation program was started after surgery, and compliance to this program was monitored using a previously described scale. Statistical analysis was performed with the obtained data.

Results

Fifty-one patients were included. The mean time between trauma and surgery was 5.7 months. Three-quarters of the patients had C5-D1, with the remainder C5-C8. Mean post-operative follow-up was 32.5 months A MRC of M4 was achieved in 62.7 % patients, M3 21.6 %, M2 in 3.9 %, and M1 in 11.8 %. The only significant differences between the two groups were in graft length (9.8 vs. 15.1 cm, p = 0.01); and in the rehabilitation compliance score (2.86 vs. 2.00, p = 0.01).

Conclusions

Results of phrenic nerve transfer are predictable and good, especially if the grafts are short and the rehabilitation is adequate. It may adversely affect respiratory function tests, but this rarely correlates clinically. Contraindications to the use of the phrenic nerve exist and should be respected.

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Conflicts of interest

The authors report no conflicts of interest concerning the materials or methods used in this study or the findings presented in this paper. No funding or financial support was received by the authors for preparation of the present paper. This original material has never been presented or published previously.

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Authors and Affiliations

  1. Nerve & Plexus Surgery Program, Division of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina

    Mariano Socolovsky, Gilda di Masi & Gonzalo Bonilla

  2. Neurosurgical Department, Hospital Regional Universitario Carlos Haya, Málaga, Spain

    Miguel Domínguez Paez

  3. Neurosurgical Department, Hospital de León, León, Spain

    Javier Robla

  4. Neurosurgical Department, Hospital de la Sabana, Bogotá, Colombia

    Camilo Calvache Cabrera

Authors
  1. Mariano Socolovsky
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  2. Gilda di Masi
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  3. Gonzalo Bonilla
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  4. Miguel Domínguez Paez
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  5. Javier Robla
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  6. Camilo Calvache Cabrera
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Corresponding author

Correspondence to Mariano Socolovsky.

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Comments

One of the prime tenets of medicine is “primum non nocere” or “first do no harm.” The desire by the physician to help must always be balanced against the risks of doing harm. This consideration becomes important and most relevant to the peripheral nerve surgeon in the clinical setting of severe brachial plexus injuries where all, or almost all, of the spinal nerve roots supplying the upper extremity have been avulsed from the spinal cord, resulting in very limited repair options involving distal neurotization of a functionally important nerve supplying the biceps muscle with an intact proximal nerve such as the spinal accessory nerve, intercostal nerves, or even the phrenic nerve as discussed in this paper. The reluctance of many peripheral nerve surgeons to use the phrenic nerve as a donor nerve to restore elbow flexion function, as noted by the authors, stems from the belief and fear that doing so either compromises the patient’s pulmonary function significantly or at the very least puts the patient at risk of suffering such a fate in the future. The results of this paper go a long way in reassuring the surgeon that many appropriately selected patients with good preoperative lung function can tolerate sacrificing phrenic nerve innervation of the diaphragm, in an effort to restore biceps function, on one side for a variety of possible reasons mediated by several possible biological mechanisms. This paper is well written and reviews the results of a large experience with severe and extensively injured brachial plexus patients. I think this paper makes an important contribution to the field and phrenic nerve neurotization is a viable repair option to the peripheral nerve surgeon when confronted with a severe brachial plexus injury that leaves him or her with very limited repair options.

Michel Kliot

Illinois, USA

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Socolovsky, M., di Masi, G., Bonilla, G. et al. The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis. Acta Neurochir 157, 1077–1086 (2015). https://doi.org/10.1007/s00701-015-2387-7

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  • DOI: https://doi.org/10.1007/s00701-015-2387-7

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