Monday, February 5, 2007

Nerve Transfer to Deltoid Muscle Using the Intercostal Nerves Through the Posterior Approach: An Anatomic Study and Two Case Reports.

(J Hand Surg [Am]. 2007 Feb;32A:218-24)



Coordinator said...

This interesting anatomical study supplemented with two case reports represents an alternative nerve transfer technique for reinnervation of the deltoid in patients with C5-C7 avulsions and weak/paralyzed triceps. Using 10 cadavers, they confirm histomorphological and length feasibility of direct intercostal to anterior division of axillary nerve coaptation via a posterior approach.

In 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.

Anonymous said...

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