OBJECTIVE: The Oberlin II double fascicular nerve transfer has been evaluated extensively for objective outcomes for elbow flexion in brachial plexus injuries (BPI). However, there is limited information available on the recovery pattern of supination and patient-reported activity in the long-term. Our study aimed to assess the functional results with a minimum of five years of follow-up.
METHODS: We evaluated patients with a minimum of five years after the Oberlin II procedure for post-traumatic BPI. They were evaluated using MRC grading, range of active movements, QuickDASH score and activity to check elbow flexion and forearm supination independent of finger and wrist flexion.
RESULTS: 18 out of 26 patients responded with a mean follow-up of 79.4 months (range: 61-98). 16 (88.9%) (p < 0.000) patients recovered to achieve active elbow flexion and forearm supination of either MRC grade 3 power or more. The average range of active elbow flexion was 113.9° (range: 0-140°) and active supination was 67.8° (0-90°). Patients who achieved grade 3 flexion or higher were found to regain supination after a delay. The recovery continues even after two years of surgery. The mean QuickDASH score was 21.8 (range: 2.3-63.6). There\'s a significant inverse correlation between QuickDASH with both flexion and supination (p < .001 and < 0.05). 15 patients (83.3%) could demonstrate a dissociation of elbow and forearm movements from digital and wrist movements.
CONCLUSIONS: Our study demonstrated reliable functional results with independent elbow flexion, forearm supination and acceptable patient-reported outcomes for Oberlin II procedure in BPI.

BACKGROUND: Isolated musculocutaneous nerve injuries occur rarely due to their anatomical location. We present our patient with a musculocutaneous nerve injury in a motorcyclist.
METHODS: The patient was initially treated for a motorcycle accident. Further examination of the patient revealed impaired elbow flexion and numbness of the lateral forearm. Electromyography confirmed impaired function of the musculocutaneous nerve. After 3 months, the patient\'s condition did not show any improvement, neither electromyography confirmed recovery of the nerve activity, so surgical treatment was planned. In the surgical revision, neuroma-in-continuity was discovered and resected. The resulting nerve defect was 6 cm long. We provided nerve grafting using sural nerve from the right lower limb. After surgery, the patient began physical therapy and electrical stimulation. Two years later, the patient reached complete recovery of muscle strength.
CONCLUSIONS: Due to the lack of improvement after a 3-month period, we proceeded with a surgical revision, which demonstrated a complete lesion of the nerve that could not heal spontaneously. Therefore, we opted for the nerve graft method and the patient regained full function of elbow flexors.

BACKGROUND: Traumatic peripheral nerve injury, with an annual incidence reported to be approximately 13-23 per 100,000 people, is a serious clinical condition that can often lead to significant functional impairment and permanent disability. Although nerve transfer has become increasingly popular in the treatment of brachial plexus injuries, satisfactory results cannot be obtained even with total nerve root transfer, especially after serious injuries. To overcome this problem, we hypothesize that the application of stem cells in conjunction with nerve transfer procedures may be a viable alternative to more aggressive treatments that do not result in adequate improvement. Similarly, some preliminary studies have shown that adipose stem cells combined with acellular nerve allograft provide promising results in the repair of brachial plexus injury. The purpose of this study was to assess the efficacy of combining adipose-derived stem cells with nerve transfer procedure in a rat brachial plexus injury model.
METHODS: Twenty female Wistar rats weighing 300-350 g and aged 8-10 weeks were randomly divided into two groups: a nerve transfer group (NT group) and a nerve transfer combined adipose stem cell group (NT and ASC group). The upper brachial plexus injury model was established by gently avulsing the C5-C6 roots from the spinal cord with microforceps. A nerve transfer from the ulnar nerve to the musculocutaneous nerve (Oberlin procedure) was performed with or without seeded allogeneic adipose tissue-derived stem cells. Adipose tissue-derived stem cells at a rate of 2 × 106 cells were injected locally to the surface of the nerve transfer area with a 23-gauge needle. Immunohistochemistry (S100 and PGP 9.5 antibodies) and electrophysiological data were used to evaluate the effect of nerve repair 12 weeks after surgery.
RESULTS: The mean latency was significantly longer in the NT group (2.0 ± 0.0 ms, 95% CI: 1.96-2.06) than in the NT and ASC group (1.7 ± 0.0 ms, 95% CI: 1.7-1.7) (p < .001). The mean peak value was higher in the NT group (1.7 ± 0.0 mV, 95% CI: 1.7-1.7) than in the NT and ASC group (1.7 ± 0.3 mV, 95% CI: 1.6-1.9) with no significant difference (p = .61). Although S100 and PGP 9.5 positive areas were observed in higher amounts in the NT and ASC group compared to the NT group, the differences were not statistically significant (p = .26 and .08, respectively).
CONCLUSIONS: This study conducted on rats provides preliminary evidence that adipose-derived stem cells may have a positive effect on nerve transfer for the treatment of brachial plexus injury. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings.

OBJECTIVE: Patients with brachial plexus birth injury with limited intraplexal donors require the use of extraplexal donors. Concern regarding the potential for respiratory problems resulting from the harvest of intercostal nerves or the phrenic nerve suggests the need for other options. Transfer of the spinal accessory nerve (SAN) is one option for restoring elbow flexion in adult patients; however, there are few reports of the results of this transfer in brachial plexus birth injury. This study aimed to report the result of SAN transfer to the musculocutaneous nerve (MCN) in brachial plexus birth injury.
METHODS: Patients who had undergone SAN to MCN nerve transfer were included in this study. Patients were classified according to Narakas classification. The chart was reviewed for the time for recovery of elbow flexion according to the Active Movement Scale (AMS).
RESULTS: Eleven patients underwent SAN to MCN transfers with interpositional sural nerve grafts. Mean birthweight was 4,070 grams (range: 3,300-4,670). Mean time to operation was 6.5 months (range: 4-10). Of the 11 patients, two were of Narakas type 3, whereas the others were of type 4. One patient did not recover elbow flexion and underwent later tendon transfer, whereas the other 10 patients reached AMS grade M6 recovery. The median time for AMS grade M1 elbow flexion recovery was eight months (interquartile range: 6.2-8.8) and for AMS grade M5 was 26 months (interquartile range: 14.2-36.5).
CONCLUSIONS: Spinal accessory nerve to MCN transfer with an interposition nerve graft is a viable option for restoring elbow flexion. However, long-term outcomes of this procedure have yet to be fully demonstrated.
METHODS: Case series IV.

UNASSIGNED: Evaluate safety and effectiveness of thermal radiofrequency in the musculocutaneous nerve in patients with focal elbow flexor spasticity.
UNASSIGNED: Ambispective observational follow-up study. Patients with focal spasticity secondary to central nervous system injury with elbow flexor pattern who received thermal radiofrequency treatment in the musculocutaneous nerve between 2021 and 2023 were included.
UNASSIGNED: 12 patients.
UNASSIGNED: Ultrasound-guided thermal radiofrequency was applied to the musculocutaneous nerve at 80°C for 90 s. Effectiveness was assessed prior to thermal radiofrequency and at 6 months using scales to measure pain (VAS), spasticity (MAS), disability (DAS), quality of life (SQol-6D), patient-perceived and physician-perceived satisfaction (PIG-C, PGA), and goal attainment (GAS). Elbow joint range of motion was evaluated via goniometry. Safety was evaluated by assessing side effects.
UNASSIGNED: Patients had statistically significant improvements in spasticity (p = 0.003), severe elbow flexion (p = 0.02), pain (p = 0.046), functioning (p < 0.05), and spasticity-related quality of life (p < 0.05 in three sections). Furthermore, treatment goals were attained. Patient- and physician-perceived clinical improvement was achieved. Regarding side effects, two patients had dysesthesia that was self-limiting, with maximum duration of 1 month.
UNASSIGNED: Thermal radiofrequency in the musculocutaneous nerve can be a safe, effective treatment for patients with severe spasticity with an elbow flexor pattern.

BACKGROUND: Spasticity of the elbow flexors causes a dynamic and/or static elbow flexion deformity. This position interferes with the functional use of the hand, is aesthetically unpleasant and can cause problems with hygiene and comfort. A lengthening procedure of elbow flexor muscles can improve elbow posture and range of motion. However, causal spasticity is not addressed directly. Selective neurectomy of the musculocutaneous nerve has a direct effect on underlying spasticity but is not sufficient when contracture is present. In this study, we examine the long-term results of a combined surgical approach: a release procedure of the elbow flexors and selective neurectomy of the musculocutaneous nerve.
METHODS: A retrospective study of 14 patients with spastic flexion deformity of the elbow was performed. After a mean follow-up of 52.6 months (SD 33, range 12 to 113), the results of the combined surgical approach were evaluated. Spontaneous position of the elbow and active and passive range of motion were assesses using goniometry. Spasticity was assessed using the Modified Ashworth Scale. Function of the affected upper limb before and after surgery was assessed by the House functional classification. Patient and caretaker\'s satisfaction were assessed using a visual analogue scale.
RESULTS: The mean decrease of passive elbow extension deficit was 34 degrees (SD 21.3, P <0.05). Active elbow extension increased with a mean of 41 degrees (SD 16.5, P <0.05). Spontaneous position elbow flexion decreased by a mean of 40 degrees (SD 21.1, P <0.05).The Modified Ashworth score decreased significantly ( P <0.05) from 3.27 (range 1 to 4) preoperatively to 0.64 (range 0 to 4) postoperatively.The difference between the House score preoperatively and postoperatively was not significant ( P =0.180). Mean patient satisfaction was 8.2/10 (SD 2.7, range 2 to 10) and mean caregiver satisfaction was 7.1/10 (SD 2.7, range 1 to 10).
CONCLUSIONS: A combined surgical approach to elbow flexion deformity in the form of a lengthening procedure and selective neurectomy of the elbow flexors result in a significant and sustained improvement of the spontaneous position, active and passive elbow extension and elbow flexor spasticity and high patient and caregiver satisfaction.
METHODS: Case series, level IV.

The anatomical variations of coracobrachialis muscle (CBM) are of great clinical importance. This study aimed to elucidate the morphological variations, innervation patterns and musculocutaneous nerve (MCN) relation to CBM. Upper limbs of fifty cadavers (30 males and 20 females) were examined for proximal and distal attachments, innervation pattern of CBM and its relation to MCN. Four morphological types of CBM were identified according to number of its heads. The commonest type was the two-headed (63.0%) followed by the single belly (22.0%), three-headed (12.0%) and lastly fourheaded (3.0%) type. Moreover, an abnormal insertion of CBM was observed in four left limbs (4.0%); one inserting into the medial humeral epicondyle, the second into the upper third of humeral shaft, the third one in the common tendon of biceps, and the fourth one showing a bifurcated insertion. Also, four different innervation patterns of CBM were identified including MCN (80.0%), lateral cord (14.0%), lateral root of median nerve (4.0%), and median nerve itself (2.0%). The course of MCN was superficial to the single belly CBM (19.0%) and in-between the heads in the other types (71.0%). Measurements of the length and original distance of CBM muscular branches originating from MCN revealed no sex or side significant difference. Awareness of the anatomic variations, innervation patterns, and MCN relation of CBM is imperative in recent diagnostic and surgical procedures to obtain definite diagnosis, effective management and good outcome.

This chapter covers axillary and musculocutaneous neuropathies, with a focus on clinically relevant anatomy, electrodiagnostic approaches, etiologic considerations, and management principles. Disorders of the lateral antebrachial cutaneous nerve, a derivative of the musculocutaneous nerve, are also reviewed. We emphasize the importance of objective findings, including the physical examination and electrodiagnostic evaluation in confirming the isolated involvement of each nerve which, along with the clinical history, informs etiologic considerations. Axillary and musculocutaneous neuropathies are both rare in isolation and most frequently occur in the setting of trauma. Less commonly encountered etiologies include external compression or entrapment, neoplastic involvement, or immune-mediated disorders including neuralgic amyotrophy, postsurgical inflammatory neuropathy, multifocal motor neuropathy, vasculitic neuropathy, and multifocal chronic inflammatory demyelinating polyradiculoneuropathy.

The brachial plexus consists of nerves that supply the upper limb and some nerves of the back, torso, and neck. It is formed by the ventral rami of C5 to T1 (in some cases, C4 or T2 also contribute). The anterior rami of the spinal nerves unite to the roots, trunks, divisions, cords, and terminal branches that innervate muscles and skin. An example is associated with terminal branches of the long nerves. Knowledge of this variation is necessary for enabling surgeons, orthopedists, and neurologists to avoid injury during surgical exploration in the arm or axilla region, and for achieving correct diagnoses, because such variability can evoke nonspecific responses. Awareness of this anastomosis is also mandatory for anesthetists performing anesthesia in the upper limb region. The aim of this article is to describe anastomoses between long nerves from the brachial plexus and to consider their clinical significance.

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