Nerve reconstruction techniques in traumatic brachial plexus surgery. Part 1: Extraplexal nerve transfers

After the great enthusiasm generated in the '70s and '80s in brachial plexus surgery as a result of the incorporation of microsurgical techniques and other advances, brachial plexus surgery has been shaken in the last two decades by the emergence of nerve transfer techniques or neurotizations. This technique consists in sectioning a donor nerve, sacrificing its original function, to connect it with the distal stump of a receptor nerve, whose function was lost during the trauma. Neurotizations are indicated when direct repair is not possible, i.e. when a cervical root is avulsed at its origin in the spinal cord. In recent years, due to the positive results of some of these nerve transfer techniques, they have been widely used even in some cases where the roots of the plexus were preserved. In complete brachial plexus injuries, it is mandatory to determine the exact numer of roots available (not avulsed) to perform a direct reconstruction. In case of absence of available roots, extraplexual nerve transfers are employed, such as the spinal accessory nerve, the phrenic nerve, the intercostal nerves, etc., to increase the amount of axons transferred to the injured plexus. In cases of avulsion of all the roots, extraplexal neurotizations are the only reinnervation option available to limit the long-term devastating effects of this injury. Given the large amount of reports that has been published in recent years regarding brachial plexus traumatic injuries, the present article has been written in order to clarify the concerned readers the indications, results and techniques available in the surgical armamentarium for this condition. Since the choice of either surgical technique is usually taken during the course of the procedure, all this knowledge should be perfectly embodied by the surgical team before the procedure. In this first part extraplexual nerve transfers are analyzed, while intraplexual nerve transfers will be analyzed in the second part of this presentation.