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Nerve transfer to deltoid muscle using the intercostal nerves through the posterior approach: an anatomic study and two case reports.
by Malungpaishrope K, Leechavengvongs S, Uerpairojkit C, Witoonchart K, Jitprapaikulsarn S, Chongthammakun SThe Journal of hand surgery.
Article Abstract:
PURPOSE: To evaluate the feasibility of restoring the deltoid function in patients with C5 through C7 root avulsion injuries by transferring 2 intercostal nerves to the anterior branch of the axillary nerve through a posterior approach. The preliminary results of the clinical application of this procedure also are reported. METHODS: The study was performed on 10 fresh cadavers. The lengths of the third, fourth, and fifth intercostal nerves from the costochondral junction to the midaxillary line were recorded. The distance from the pivot point at the midaxillary line to the anterior branch of the axillary nerve was recorded as the tunnel length. All histomorphometric measurements of the axon number were recorded. Based on the anatomic study, the fourth and fifth intercostal nerves were transferred directly to the anterior branch of the axillary nerve in 2 patients. RESULTS: The average distances from the costochondral junction of the third, fourth, and fifth intercostal nerves to the pivot points were 12, 15, and 16 cm, respectively. The average tunnel distances of the third, fourth, and fifth intercostal nerves were 11, 13, and 15 cm, respectively. The average numbers of myelinated nerve fibers of the third, fourth, and fifth intercostal nerves were 742, 830, and 1,353, respectively. At the 2-year follow-up evaluation the preliminary clinical results showed that the deltoid recovered against resistance (M4). The range of motion for shoulder abduction and external rotation were both 95 degrees in the first case and 105 degrees and 95 degrees , respectively, in the second case. Useful functional recovery was achieved and classified as a good result in both patients. CONCLUSIONS: This anatomic study with 2 case reports supports the idea that transfer of 2 intercostal nerves to the anterior branch of the axillary nerve through the posterior approach could be an alternative method for reconstruction of the deltoid muscle in C5 through C7 root avulsion injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Nerve transfer to deltoid muscle using the intercostal nerves through the posterior approach: an anatomic study and two case reports.
By: Anonymous - Tue 2/27/2007 PMIn patients with C5-C7 avulsions, the triceps can still be quite powerful (presumably from C8 contribution), thereby not precluding a triceps branch to axillary transfer in select patients. Of note, they did not mention triceps strength in their case reports. Nevertheless, when the triceps is weak or paralyzed, nerve transfer options remain limited to the medial pectoral (if phrenic/contra C7 are not used and accessory goes to the suprascapular). Many authors have reported success with this option. However, the advantages of the posterior intercostal transfer include selective neurotization of the anterior division, close proximity to the motor endplates, and in my mind (not mentioned in the discussion): bypassing the quadrilateral space, where a tandom stretch injury may be present.
A significant concern about this approach is getting the intercostals to reach the axillary nerve from a posterior approach. Their anatomical meusurements came a little too close for comfort, with the tunnel and harvest length overlapping (i.e., in some cases it would not have reached). Although they measured to the costochondral margin, sometimes the intercostal nerves become too small to readily preserve up to this point. Furthermore, why did they not use the third intercostal in their two patients, did it not reach? In C5-C7 avulsions, the long thoracic could use input, perhaps an intercostal should be placed there also.
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