Comparison of Anterior vs. Dorsal Approach for Spinal Accessory to Suprascapular Nerve Transfer in Patients With a Brachial Plexus Injury and Its Outcome on Shoulder Function

Abstract

Background Brachial plexus injuries are frequently encountered in the domain of plastic surgery, mostly secondary to road traffic accidents, gunshot injuries, or falls from a height. Many modalities have been described in the management, depending on the level and duration of the injury. C5, C6 and C5, C6, C7 are two common patterns in which nerve repair and transfers are described. At our center, we practice spinal accessory to suprascapular nerve transfer in all patients with upper trunk brachial plexus injury. There are two described approaches for the spinal accessory nerve to suprascapular nerve transfer, i.e. anterior or dorsal. The rationale for doing the posterior approach is that this approach avoids damaging the suprascapular nerve at its entrance in the suprascapular notch under the suprascapular ligament during exploration due to traction. Materials and methods This is a retrospective study with a consecutive sampling of 23 patients presenting at Liaquat National Hospital, Karachi, with upper trunk brachial plexus injuries during the time period from January 2016 to December 2017, i.e. two years. We divided these 23 patients into two groups, one with the anterior approach and the other with a dorsal approach for spinal accessory to suprascapular nerve transfer for shoulder abduction. The mean duration of post-surgical follow-up was from 18 to 24 months and recovery and functional outcomes were assessed. Results Out of the 23 patients that were included, 10 patients were operated on with an anterior approach and 13 with a posterior approach. Fifty percent (50%) of patients operated with the anterior approach and 84% of patients with the posterior showed the best motor grade recovery of M4, respectively, with better performance in patients with the posterior approach as compared to the anterior approach. Conclusion We advocate taking a posterior approach for spinal accessory to suprascapular nerve transfer for shoulder abduction, as it has shown better results with reliable outcomes concerning shoulder abduction, angle of abduction, and range of motion.

Keywords: anterior approach; bilateral brachial plexus injury; dorsal approach; nerve transfer; shoulder function; spinal accessory nerve; suprascapular nerve.

Figure 1. Surgical marking on the patient undergoing nerve transfer via the posterior approach

Figure 2. Intraoperative view of spinal accessory nerve and suprascapular nerve being identified and isolated

Figure 3. Demonstrates the MRC grades achieved by patients in respective groups

MRC: medical research council

Figure 4. Demonstrates the improvement in MRC grades over the 03, 06, 12, 18, and 24 months follow-up for shoulder abduction in each group

MRC: medical research council

Figure 5. Intraoperative view of coaptation of the two nerves via the posterior approach