Brachial plexus injuries: outcome following neurotization with intercostal nerve

Transcription

1 J Neurosurg 107: , 2007 Brachial plexus injuries: outcome following neurotization with intercostal nerve ALIASGAR VAJIHUDDIN MOIYADI, M.CH., 1 BHAGAVATULA INDIRA DEVI, M.CH., 1 AND K. P. SIVARAMAN NAIR, D.M. 2 Departments of 1 Neurosurgery and 2 Psychiatric and Neurological Rehabilitation, National Institute of Mental Health and Neurosciences, Bangalore, India Object. Brachial plexus root avulsion injuries, which are devastating, usually result from high-speed accidents. Nerve transfer provides hope for successful treatment of this difficult set of injuries. Nevertheless, the controversies regarding indications, techniques, and outcome of the various available surgical procedures continue. Methods. A retrospective analysis was performed in 51 patients (43 male and eight female patients) with brachial plexus injuries who underwent neurotization at the authors institute between 1997 and Clinical, electrophysiological, and imaging data were used to identify the type and pattern of involvement of the various elements of the plexus. The mean duration of denervation was 6.4 months (range 2 24 months). Outcome was computed in terms of the overall improvement in power of the target muscle as well as the functional usefulness of such recovery. Results. There were 50 supraclavicular injuries (25 preganglionic, eight postganglionic, and 17 mixed). One patient had an infraclavicular (posterior spinal cord) injury. Pan brachial plexus injury with a flail upper limb was the most common pattern. Overall, 55 nerves were neurotized 33 musculocutaneous, 18 axillary, and two each for ulnar and radial nerves (47 single and four double neurotizations by using intercostal nerve donors in the majority of cases. Adequate follow-up data were available in 36 patients (38 nerves) and these were used for the analysis of outcome. Overall, 58.3% of patients had improvement, and of these 62% achieved useful recovery. This accounted for 36% of overall useful recovery. Multiple logistic regression analysis revealed that regardless of age, sex, mode and pattern of injury, and recipient nerve, the duration of denervation showed a trend toward significance that correlated with overall (but not useful) improvement. The critical duration of denervation was 5.5 months. Conclusions. Neurotization for brachial plexus root avulsion injuries is a viable option. Early detection and intervention (within 5.5 months) leads to a better overall recovery. (DOI: /JNS-07/08/0308) KEY WORDS brachial plexus injury intercostal nerve neurotization outcome analysis root avulsion B Abbreviations used in this paper: ICN = intercostal nerve; MR = magnetic resonance; ROC = receiver operating characteristic. RACHIAL plexus injuries in the adult population, although uncommon, may be devastating because of the resulting severe functional impairment of the upper extremity. Underdiagnosis is usual in the presence of associated vascular and other life-threatening injuries. 8,11, 22,24 Avulsions are the most challenging of all types of brachial plexus injuries. Since the first attempt at neurotization by Low and Tuttle (as related by Naff and Ecklund 16 ), and Seddon s 23 pioneering work on ICN neurotization, others including Narakas and Hentz 18 have introduced various other refinements. 9 Intervention is now aimed at reanimation of the limb and relief of pain, if present. Despite renewed interest and the literature generated in the last several decades about brachial plexus injuries, especially those caused by stretch or traction, there is no unanimity regarding the management of these difficult problems. 1,3,12 In a recent multinational survey of peripheral nerve surgeons, Belzberg et al. 2 found significant differences in the approaches used among different practitioners. These authors highlighted the significant disagreement in many areas, including the diagnostic approach, the timing of and indications for surgical intervention, and the choice of surgical procedures. Both the surgeon and the patient must realize at the outset that even in the best of hands, only a functional (and not a normal) recovery is possible. The socioeconomic impact of such palsies is high, because these injuries usually occur in young men who are in the prime of life. After the injury, the patient faces either permanent disability or a prolonged rehabilitation time. One quarter to one third of patients with severe injuries do not regain any useful function in the upper limbs. 9 We present our experience with ICN neurotization in brachial plexus injuries. Clinical Material and Methods A retrospective analysis of all patients with traumatic brachial plexus injuries who underwent a neurotization procedure at our center between 1997 and 2003 was per- 308 J. Neurosurg. / Volume 107 / August, 2007

2 Neurotization for brachial plexus injuries formed. Evaluation consisted of a review of the records of these patients, including the operative notes and investigations. The Medical Research Council (British) system was used to assess the power of the muscle involved. Pain was graded into three categories by using the method of Bruxelle et al. 4 Findings on x-ray films of the cervical spine, shoulder, and chest as well as computed tomography myelography or MR imaging (if available) were recorded. Electrophysiological testing was available in all patients preoperatively. This was performed more than 4 weeks after the injury in all cases. Besides evidence of denervation or regeneration, specific features that we looked for to identify root avulsion included paraspinal denervation and the presence of sensory nerve action potentials in anesthetized nerves. Electrophysiological indicators of root avulsion were supplemented with clinical clues (deafferentation pain, Horner syndrome, absent Tinel sign, and weakness of rhomboid and serratus muscles) to diagnose preganglionic injury. Patient Characteristics Of the 51 patients who underwent neurotization at our institution between 1997 and 2003, 43 were male and eight were female. Most were between 21 and 40 years of age (Table 1); the mean age was 28.7 years. There were two children younger than 10 years of age. Inclusion Criteria The 51 patients included in this study had undergone neurotization based on the following criteria. Clinical Criteria. These included the following: 1) indicators of avulsion (traction injury, Horner syndrome, rhomboid and paraspinal weakness, and/or absent Tinel sign); and 2) failure of regeneration over a period of 4 to 6 months, even if the trauma was not an avulsion injury. Electroneuromyography Findings. These included the following: 1) evidence of paraspinal denervation; and 2) normal sensory nerve action potentials in limb nerves in the presence of anesthesia. Imaging Studies. For a case to be included, there had to be evidence of pseudomeningoceles on neuroimaging studies. Operative Details J. Neurosurg. / Volume 107 / August, 2007 TABLE 1 Age distribution in 51 patients with brachial plexus injuries treated with neurotization* The goal of surgery was to restore elbow flexion and/or shoulder abduction in the patients with upper-trunk (C-5 and C-6) or pan brachial plexus palsies. All 51 patients in this study underwent neurotization without supraclavicular exploration. Of these, 47 had a single-nerve neurotization (musculocutaneous in 29, axillary in 15, radial in two, and ulnar in one), and three patients had a simultaneous twonerve neurotization (musculocutaneous plus axillary nerve in two and musculocutaneous plus ulnar in the other). One more patient who had a good outcome with musculocutaneous nerve neurotization subsequently underwent axillary nerve neurotization. Overall, 55 nerves were neurotized (33 musculocutaneous, 18 axillary, and two each for radial and ulnar). The ICNs were used in 49 patients. These were dissected up to the midaxillary or anterior axillary line as in the standard technique and then tunneled into the axilla to be anastomosed to the target nerve (axillary/musculocutaneous/radial, and so on) as close to the target muscle as possible. One or a maximum of two ICNs (commensurate with thinnedout recipient nerve trunks) were used. Sural nerve cable graft was used in all but one case (a child in whom the sural nerve was deemed to be too thin and for whom silicone tubes were used). Split-nerve anastomosis was performed when possible. One patient had musculocutaneous neurotization in which the medial pectoral nerve was used, and a split median nerve donor was used in another. There were no major postoperative complications. In two patients small pleural tears occurred during ICN dissection. These did not require intercostal drainage and recovery was uneventful. Postoperative Outcome Serial follow-up review was recorded (case records, postal correspondence, and personal review if available) and a neurologist and the operating surgeon assessed the outcome independently. Although both the surgeon and the neurologist assessed the patient at follow-up, to ensure uniformity and unbiased assessment, only the neurologist s findings were used for the purpose of analysis. Outcome was evaluated in terms of power in the muscle neurotized; this was categorized as improved or unchanged. In the improved group, results were categorized as follows: poor, power less than M2 (active joint motion present with gravity eliminated); fair, power M3 (muscle can move joint through full range of motion against gravity); or good, power M4 or greater (full range of motion against gravity and some resistance). The useful recovery rate was calculated as the proportion of patients with improvement who had fair and good results. The pain score was also noted at follow-up evaluation. Selective electrophysiological evaluation was done when possible to look for evidence of reinnervation. This included electromyographic records from the muscle that was neurotized and recording of motor responses on stimulation of the Erb point as well as the site of origin of the ICN donor. Statistical Analysis No. of Patients Age Group (yrs) Overall w/ FU total * FU = follow-up. Statistical analysis was performed using the standard SPSS version 11.0 software. Data were expressed using descriptive statistics, namely the mean, standard deviation, 309

3 A. V. Moiyadi, B. I. Devi, and K. P. S. Nair percentages, and so on. Univariate analysis was performed to ascertain the influence of variables on the outcome (both the overall and functionally useful outcome). The continuous variables (age, duration of denervation, and duration of follow-up) were compared among groups by using the Student independent-sample t-test. The categorical variables (sex, mechanism and mode of injury, and recipient nerve) were analyzed using the chi-square and Fisher exact tests. A probability value of less than 0.05 was considered significant. To find the best prognostic factor after adjusting for the confounding effect of other variables, multiple logistic regression analysis was used. The ROC curve was used to study the critical duration of denervation. Clinical Profile Results Besides weakness, 22 patients reported numbness, and pain was significant in seven. The duration of denervation ranged from 2 to 28 months (mean 6.4 months). None of the patients were seen immediately after the injury; 25 were seen within 6 months, 21 within 1 year, and five patients were seen more than 1 year after the injury. Motor vehicle accidents accounted for 43 (84%) of the 51 injuries. Of the 51 patients, 23 (45%) had an associated major systemic injury, the most common being head injury; 16 had local bone injury, and one also had local vascular injury. Falls and assaults with weapons leading to irregular lacerations accounted for the rest of the brachial plexus injuries. Stretch contusion (traction) injury occurred in 90% of the patients (Table 2), with open injuries occurring in the remaining five. These five patients had undergone supraclavicular exploration at other institutions before coming to us. Most (43) of the 51 patients had a power of 0/5 in the involved muscle. Eight had partial injuries with varying degrees (Scores 1/5 3/5) of residual power. In 49 patients x-ray films of the limb involved were available. Sixteen patients had local bone injuries. Fifteen had been evaluated with computed tomography myelography and/or MR imaging; in six of these pseudomeningoceles were detected and in two others neuromas were revealed on MR imaging. Pattern of Injury Fifty patients had supraclavicular lesions. Of these, 42 had preganglionic injury (17 of whom had a combined preand postganglionic injury), and there were eight patients with only postganglionic injury. In addition to the 50 with supraclavicular injuries, one patient had an infraclavicular posterior spinal cord injury. Pan brachial plexus injury with a flail limb was the most common pattern of involvement. The distribution of the pattern and level of injury for the supraclavicular lesions were as shown in Table 3. None of the patients had electrophysiological evidence of reinnervation prior to the surgical procedure. TABLE 2 Type of injuries in 51 patients with brachial plexus lesions Injury Type No. of Patients traction 46 laceration 3 penetrating 2 total 51 Follow-Up Evaluation and Outcome Demographic Features of the Follow-Up Group. Followup data were available in 36 of these patients (38 nerves), and the duration of follow-up ranged from 3 to 75 months (mean 22.3 months, median 17 months). Twenty-two patients had a follow-up duration of more than 1 year. There were 28 males and eight females in whom follow-up data were available; the age distribution in these individuals was as shown in Table 1. The mean age in this group was 28.5 years and the mean duration of denervation was 6.4 months. All but one of these patients had undergone neurotization in which the ICN was used as the donor. Motor Outcome. Overall, improvement was seen in 21 patients (55.2%). Of these patients, eight had a muscle power of M2 or less, eight had a power of M3, and five had power of M4 or more. Thus, useful recovery (Score M3) occurred in 13 (62%) of the 21 patients. These represented 36% of the entire group of 36 patients. The outcome in those with more than a 1-year follow-up duration (22 patients) and in those with less than 1-year follow-up periods (14 patients) are shown in Tables 4 and 5, respectively. With longer follow-up periods it was seen that the rates of useful recovery were better. The outcome for each of the recipient nerves is shown in Table 6. The recovery and useful recovery rates for the musculocutaneous nerve were 54.5 and 58.3%, respectively, and for the axillary nerve the rates were both 66.7%. Of the 36 patients available for follow-up review, 35 had ICN donors. Muscle power in the single patient with medial pectoral musculocutaneous nerve neurotization had improved to 2/5 at 4 months of follow-up. The follow-up data were not available for the patient with a median musculocutaneous nerve neurotization. Predictors of Outcome. The influence of various factors (age, sex, mechanism of injury, mode/type of injury, duration of denervation, and recipient nerve) on outcome was assessed using univariate analysis. This was computed between two sets of groups: between the improved (21) and the unchanged (15) patients; and between the useful (13) and the nonuseful (23) recovery groups. In both instances, there was no significant difference in the follow-up duration between the two groups in both the sets. TABLE 3 Patterns of supraclavicular injuries in 50 patients* C-5 & C-6 C-7 C8 T1 Upper Pattern Roots Roots Roots PBPI Trunk Total preganglionic postganglionic combined total * One patient had an infraclavicular posterior spinal cord injury. Abbreviation: PBPI = pan brachial plexus injury. Two patients had an additional middle trunk injury. 310 J. Neurosurg. / Volume 107 / August, 2007

4 Neurotization for brachial plexus injuries TABLE 4 Outcome in 22 patients with more than 1 year of follow-up Outcome No. of Patients (%) unchanged 9 (41) improved* 13 (59) poor 4 fair 5 good 4 * When fair and good outcomes are combined, nine (69%) of 13 patients had a useful recovery. Multiple logistic regression analysis was performed to adjust for the confounding effect of other variables. It showed that the duration of denervation was the single most important predictor of improvement (p = 0.082). The model predicted the nonimprovement with 80% sensitivity and 71.45% specificity. Nevertheless, no variable was found to be able to predict useful functional recovery. The ROC curve was used to study the critical denervation time that distinguished overall improvement from nonimprovement. The area under the curve was with a standard error of 0.09, which is significant at probability values of 0.014, corresponding to a 5.5-month denervation time. Sensitivity for this value was 80% and specificity was 71.4%, which maximizes both sensitivity and specificity. The same curve was applied to determine the critical denervation time between the functionally improved (useful improvement) and functionally nonimproved groups. Although the same duration of 5.5 months was obtained, it was not significant. The curves are as shown in Fig. 1. Discussion Our experience reflected the pattern of referral to a tertiary neurosurgical care facility. Most patients were referred a long time after the initial injury, some of them after failed surgical attempts had been made elsewhere. Male patients predominated in this study, with most of them in the third and fourth decades of life. The male/female ratio was 5.4:1, with a mean age of 28.7 years, reflecting the high incidence of such injuries in young adult males. 6,22,24,25 Motor vehicle accidents (85%) were the most common mechanism of injury in our patients. In an epidemiological review in 1997, Midha 14 found that road accidents account for more than half of such injuries. This has been the case in many other reports. 6,22,24,25 Most of our patients had stretch contusion (traction) types of injuries necessitating TABLE 5 Outcome in 14 patients with less than 1 year of follow-up Outcome No. of Patients (%) unchanged 6 (43) improved* 8 (57) poor 4 fair 3 good 1 * When fair and good outcomes are combined, four (50%) of eight patients had a useful recovery. J. Neurosurg. / Volume 107 / August, 2007 TABLE 6 Outcome in 36 patients who underwent neurotization of various nerves (38 nerves)* a neurotization procedure. We also had five patients with nontraction injuries. These patients had undergone a supraclavicular exploration in an attempt at reinnervation elsewhere, and when that procedure failed they had been referred to our institution. Neurotization was offered to these as a salvage procedure. All but one of our patients had a supraclavicular injury. Midha 14 noted that patients with supraclavicular lesions had more severe injuries than those in the infraclavicular group. That could be the reason for our cases being predominantly supraclavicular, assuming that only the more severe injuries were referred to us. The predominant pattern that we encountered was a pan brachial plexus injury with involvement of all roots. Most of the patients undergoing neurotization (42 of 51) had a preganglionic component of injury, which precluded any other type of reinnervation procedure. Eight patients had a postganglionic injury; of these, three had presented within 6 months postinjury. The injury was an irregular laceration in each of these three cases in which previous local exploration had been attempted elsewhere. The other five had presented more than 6 months postinjury with no evidence of regeneration in the upper trunk innervated muscles. Hence, these eight patients also underwent neurotization, as did the only patient with a partial posterior spinal cord injury, who presented 17 months postinjury after a failed attempt at local nerve repair. Outcome After Neurotization Outcome (no. of patients) Recipient Un- Nerve changed Poor Fair Good Total MC axillary ulnar radial MC ulnar MC axillary * MC = musculocutaneous. For both nerves. For MC nerve only. The clinical profile (age, duration of denervation, and mechanism of injury) of the 36 patients available for follow-up evaluation was similar to the entire group of 51 patients. Overall recovery and useful recovery rates for the follow-up group were 55.2 and 62%, respectively. There was no statistically significant difference between the outcomes for the axillary and musculocutaneous nerves. Comparing these results with other series is very difficult because different authors use different criteria. The complicating factors include heterogeneity of the patient population; variability in the grading systems used to assess the extent and severity of the injuries; differing management strategies, including the indications for surgical intervention; availability of a large number of procedures, with numerous modifications of basic techniques; variability in 311

5 A. V. Moiyadi, B. I. Devi, and K. P. S. Nair FIG. 1. Graphs showing the ROC curve for overall (left) and functional (right) improvement. AUC = area under curve. outcome assessment scales used; and variability in the follow-up durations in various studies. All results therefore need to be considered in light of these inconsistencies. Reported overall recovery rates for musculocutaneous and axillary nerves are highly variable, ranging from 33 to 88%. 5,7,10,13,15,18 20,24,26 Over the years, with improvement in microsurgical techniques, better results have been obtained. 23 Ploncard 19 proposed direct coaptation of the ICN to the musculocutaneous nerve. He reported three good, four satisfactory, and one poor outcome in a series of eight patients who underwent this treatment. Terzis et al. 25 also support this technique, claiming excellent results (better than with other extraplexal donors) for musculocutaneous nerve reinnervation. This is also the case with Nagano et al. 17 in their series of 146 patients, in whom muscle power of M3 or more was obtained in 70% of cases. Nevertheless, this technique would involve dissection of the ICN anteriorly, with resultant loss of available motor axons. Hence, Narakas and Hentz 18 and Dubuisson and Kline 6 used graft interpositioning, achieving 50 and 56.7% recovery rates, respectively (the grading systems varied and hence are not comparable). Samardzic and colleagues 20,21 supported the intermediate technique, which involves exposure of the ICN between the midaxillary and midclavicular lines, permitting direct coaptation or anastomosis with shorter grafts. They reported functional recovery rates almost twice as high as for the standard technique that involves exposure of the ICN at the midaxillary line and use of longer grafts. In patients in whom the ICN was used as donor, Samardzic et al. 20 reported overall and useful recovery rates of 50 and 57%, respectively, for the musculocutaneous nerve and 63 and 33% for the axillary nerve. This compares well with our results, except for the quality of recovery for the axillary nerve, which was significantly higher in our patients. We adopted the same intermediate technique of neurotization. Factors Influencing Outcome Recovery is a time-dependent event; hence, rates of recovery may vary depending on the follow-up duration. In our study we compared the follow-up duration between the improved and unchanged groups as well as between the useful and nonuseful recovery groups. There was no significant difference in the follow-up periods across these groups, and therefore we could compare the influence of other variables on the outcome. We also applied the multiple logistic regression model to adjust for the confounding effect of other variables. Pattern and Severity of Injury. Dubuisson and Kline 6 reported a 78% rate of good recovery in cases of open brachial plexus injuries and a significantly lower (58%) rate of good recovery in closed injuries. Terzis et al. 25 found that postganglionic lesions recovered significantly better than preganglionic avulsions. Within the former group, no difference was noted between supra- and infraclavicular lesions. These authors also found a positive correlation with their severity score (that is, the more severe the injury, the worse the outcome). Our study revealed no difference in the recovery rates (overall or useful recovery), depending on the pattern or clinical level of the injury. Duration of Denervation. Yamada et al. 26 reported significantly better outcomes for various coaptation procedures done within 6 weeks postinjury. Narakas and Hentz 18 and Millesi 15 also support early repair. They report good results, however, even with repairs done up to 9 months after denervation. Samii et al. 22 report improvement with procedures done within 7 months of injury. In their series of 204 patients, Terzis et al. 25 found that duration of denervation of less than 6 months was important for biceps reinnervation and not for other muscles. (Their results, however, were expressed not as a percentage of the total number of patients improved but as a percentage increase of power in each muscle reinnervated.) Other authors have found no correlation. 21 Our results showed that overall improvement was better with early surgery, but even with early surgery not all patients may achieve a functional recovery. We also were able to calculate that the critical duration of denervation influencing overall improvement was 5.5 months. Recipient Nerves. Variability in the techniques used does not permit an accurate comparison between various targets of the neurotization procedure. In general, however, rates of recovery for the musculocutaneous and axillary nerves are comparable. There is evidence 15,21 to suggest that the quality of recovery may be better for the musculocutaneous nerve. We found that both the overall and the useful recovery were marginally better with the axillary nerve, but this difference was not significant across the groups. Fifteen of our patients were not available for follow-up evaluation. Some patients were unable to attend the clinic due to socioeconomic problems, and in some the addresses provided were incorrect or changed. Moreover, a significant number of patients in the early part of the study had been referred late following the injury, sometimes after failure of other reinnervation procedures. In these patients neurotization was therefore offered as a last resort, and the improbability of improvement was emphasized preoperatively. It is possible that these patients may not have been motivated enough to participate in the follow-up review. Hence not all patients could be assessed. Some of those who were lost to follow-up may have improved. Furthermore, as we have seen in our own results, better outcomes are seen in patients whose cases are followed longer. In those who had adequate follow-up in our study, the outcome status was said to have been evaluated on the day when the last follow-up review was recorded. Longer follow-up of these patients may yield better outcomes. How- 312 J. Neurosurg. / Volume 107 / August, 2007

6 Neurotization for brachial plexus injuries ever, limited by the 30% loss of patients to follow-up, the results may be a best-case computation of outcome. Conclusions Reinnervation following brachial plexus injuries is very challenging. Neurotization of the musculocutaneous and axillary nerves for reanimation of a flail limb is a viable and useful alternative. Outcomes are better when procedures are done within 6 months of injury. Normalization of function, however, remains a challenge. References 1. Alnot JY: Traumatic brachial plexus palsy in the adult. Retro- and infraclavicular lesions. Clin Orthop Relat Res 237:9 16, Belzberg AJ, Dorsi MJ, Storm PB, Moriarity JL: Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons. J Neurosurg 101: , Birch R: Injuries to the brachial plexus: controversies and possibilities. Neurosurg Clin N Am 12: , Bruxelle J, Travers V, Thiebaut JB: Occurrence and treatment of pain after brachial plexus injury. Clin Orthop Relat Res 237: 87 95, Chuang DC, Yeh MC, Wei FC: Intercostal nerve transfer of the musculocutaneous nerve in avulsed brachial plexus injuries: evaluation of 66 patients. J Hand Surg [Am] 17: , Dubuisson AS, Kline DG: Brachial plexus injury: a survey of 100 consecutive cases from a single service. Neurosurgery 51: , Friedman AH, Nunley JA II, Goldner RD, Oakes WJ, Goldner JL, Urbaniak JR: Nerve transposition for the restoration of elbow flexion following brachial plexus avulsion injuries. J Neurosurg 72:59 64, Glasby MA, Hews TE: Repairing spinal roots after brachial plexus injuries. Paraplegia 33: , Gutowski K, Orenstein HH: Restoration of elbow flexion after brachial plexus injury: the role of nerve and muscle transfers. Plast Reconstr Surg 106: , Kawai H, Kawabata H, Masada K, Ono K, Yamamoto K, Tsuyuguchi Y, et al: Nerve repairs for traumatic brachial plexus palsy with root avulsion. Clin Orthop Relat Res 237:75 86, Kim DH, Cho YJ, Tiel RL, Kline DG: Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center. J Neurosurg 98: , Kline DG: Surgical repair of brachial plexus injury. J Neurosurg 101: , Malessy MJ, Thomeer RT: Evaluation of intercostal to musculocutaneous nerve transfer in reconstructive brachial plexus surgery. J Neurosurg 88: , Midha R: Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery 40: , Millesi H: Brachial plexus injuries. Nerve grafting. Clin Orthop Relat Res 237:36 42, Naff NJ, Ecklund JM: History of peripheral nerve surgery techniques. Neurosurg Clin N Am 12: , Nagano A, Tsuyama N, Ochiai N, Hara T, Takahashi M: Direct nerve crossing with the intercostal nerve to treat avulsion injuries of the brachial plexus. J Hand Surg [Am] 14: , Narakas AO, Hentz VR: Neurotization in brachial plexus injuries. Indication and results. Clin Orthop Relat Res 237:43 56, Ploncard P: A new approach to the intercosto-brachial anastomosis in the treatment of brachial plexus paralysis due to root avulsion. Late results. Acta Neurochir (Wien) 61: , Samardzic M, Rasulic L, Grujicic D, Milicic B: Results of nerve transfers to the musculocutaneous and axillary nerves. Neurosurgery 46:93 103, Samardzic MM, Rasulic LG, Grujicic DM: Results of cable graft technique in repair of large nerve trunk lesions. Acta Neurochir (Wien) 140: , Samii M, Carvalho GA, Nikkhah G, Penkert G: Surgical reconstruction of the musculocutaneous nerve in traumatic brachial plexus injuries. J Neurosurg 87: , Seddon H (ed): Surgical Disorders of the Peripheral Nerves, ed 2. Edinburgh: Churchill Livingstone, Sedel L: The results of surgical repair of brachial plexus injuries. J Bone Joint Surg Br 64:54 66, Terzis JK, Vekris MD, Soucacos PN: Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg 104: , Yamada S, Lonser RR, Iacono RP, Morensky JD, Bailey L: Bypass coaptation procedures for cervical nerve root avulsion. Neurosurgery 38: , 1996 Manuscript submitted May 23, Accepted November 7, Address reprint requests to: Bhagavatula Indira Devi, M.Ch., Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore , India. bindira@nimhans. kar.nic.in. J. Neurosurg. / Volume 107 / August,