Nerve Transfer for Elbow Flexion in Radiation-Induced Brachial Plexopathy: A Case Report

Abstract

Radiation-induced brachial plexopathy is an uncommon but devastating late complication seen in patients receiving radiation therapy to the chest wall and axilla. Treatment options are unfortunately limited. We report a case of a 59-year-old woman treated with radiation therapy for breast cancer 12 years earlier, who presented with loss of elbow flexion and marked shoulder weakness. Electromyogram and intraoperative stimulation of the musculocutaneous nerve branches were consistent with a proximal motor nerve conduction block. Microsurgical transfer of median and ulnar nerve fascicles to the biceps and brachialis branches of the musculocutaneous nerve, respectively, were performed. The patient recovered MRC grade 4/5 elbow flexion after surgery. The characteristics of this disorder and surgical treatment options are reviewed.

Keywords

Nerve transfer Radiation brachial plexopathy Fascicular transfer

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References

1 Ahmad

Barrington

Maisey

Rubens

. Use of positron emission tomography in evaluation of brachial plexopathy in breast cancer patients. Br J Cancer 1999;79 3–4:478–82. doi:10.1038/sj.bjc.6690074.

2 Bowen

Verma

Brandon

Fiedler

. Radiation-induced brachial plexopathy: MR and clinical findings. AJNR Am J Neuroradiol 1996;17 10:1932–6.

3 Boyaciyan

Oge

Yazici

Aslay

Baslo

. Electrophysiological findings in patients who received radiation therapy over the brachial plexus: a magnetic stimulation study. Electroencephalogr Clin Neurophysiol 1996;101 6:483–90.

4 Brunelli

Brunelli

. Surgical treatment of actinic brachial plexus lesions: free microvascular transfer of the greater omentum. J Reconstr Microsurg 1985;1 3:197–200.

5 Chen

. Restoration of elbow flexion by modified Steindler flexorplasty. Int Orthop 2000;24 1:43–6. doi:10.1007/s002640050011.

6 Eggers

Mennen

Matime

. Elbow flexorplasty: a comparison between latissimus dorsi transfer and Steindler flexorplasty. J Hand Surg 1992;17 5:522–5. Br.

7 Esteban

Traba

. Fasciculation-myokymic activity and prolonged nerve conduction block. A physiopathological relationship in radiation-induced brachial plexopathy. Electroencephalogr Clin Neurophysiol 1993;89 6:382–91. doi:10.1016/0168-5597 (93)90111-2.

8 Fathers

Thrush

Huson

Norman

. Radiation-induced brachial plexopathy in women treated for carcinoma of the breast. Clin Rehabil 2002;16 2:160–5. doi:10.1191/0269215502cr470oa.

9 Fu

Gordon

. Contributing factors to poor functional recovery after delayed nerve repair: prolonged denervation. J Neurosci 1995;15 5:3886–95.

10.

10 Glantz

Burger

Friedman

Radtke

Massey

Schold

Jr . Treatment of radiation-induced nervous system injury with heparin and warfarin. Neurology 1994;44 11:2020–7.

11.

11 Glazer

Lee

Levitt

Heiken

Ling

Totty

. Radiation fibrosis: differentiation from recurrent tumor by MR imaging. Radiology 1985;156 3:721–6.

12.

12 Harper

Jr Thomas

Cascino

Litchy

. Distinction between neoplastic and radiation-induced brachial plexopathy, with emphasis on the role of EMG. Neurology 1989;39 4:502–6.

13.

13 Hussussian

Mackinnon

. Postradiation neural sheath sarcoma of the brachial plexus: a case report. Ann Plast Surg 1999;43 3:313–7. doi:10.1097/00000637-199909000-00017.

14.

14 Johansson

Svensson

Denekamp

. Dose response and latency for radiation-induced fibrosis, edema, and neuropathy in breast cancer patients. Int J Radiat Oncol Biol Phys 2002;52 5:1207–19. doi:10.1016/S0360-3016(01)02743-2.

15.

15 Johansson

Svensson

Larsson

Denekamp

. Brachial plexopathy after postoperative radiotherapy of breast cancer patients—a long-term follow-up. Acta Oncol 2000;39 3:373–82. doi:10.1080/028418600750013140.

16.

16 Killer

Hess

. Natural history of radiation-induced brachial plexopathy compared with surgically treated patients. J Neurol 1990;237 4:247–50. doi:10.1007/BF00314628.

17.

17 Kori

. Diagnosis and management of brachial plexus lesions in cancer patients. Oncology 1995;9 8:756–60. Williston Park.

18.

18 Kori

Foley

Posner

. Brachial plexus lesions in patients with cancer: 100 cases. Neurology 1981;31 1:45–50.

19.

19 Lederman

Wilbourn

. Brachial plexopathy: recurrent cancer or radiation? Neurology 1984;34 10:1331–5.

20.

20 LeQuang

. Postirradiation lesions of the brachial plexus. Results of surgical treatment. Hand Clin 1989;5 1:23–32.

21.

21 Lu

Gong

Liu

Wang

Zhang

. Diagnosis and operative treatment of radiation-induced brachial plexopathy. Chin J Traumatol 2002;5 6:329–32.

22.

22 Mackinnon

Novak

Myckatyn

Tung

. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg 2005;30 5:978–85. Am. doi:10.1016/j.jhsa.2005.05.014.

23.

23 Maggi

Lowe

III Mackinnon

. Pathophysiology of nerve injury. Clin Plast Surg 2003;30 2:109–26. doi:10.1016/S0094-1298(02)00101-3.

24.

24 Monreal

. Steindler flexorplasty to restore elbow flexion in C5–C6–C7 brachial plexus palsy type. J Brachial Plex Peripher Nerve Inj 2007;2:15. doi:10.1186/1749-7221-2-15.

25.

25 Narakas

. Operative treatment for radiation-induced and metastatic brachial plexopathy in 45 cases, 15 having an omentoplasty. Bull Hosp Jt Dis Orthop Inst 1984;44 2:354–75.

26.

26 Nich

Bonnin

Laredo

Sedel

. An uncommon form of delayed radio-induced brachial plexopathy. Chir Main 2005;24 1:48–51. doi:10.1016/j.main.2004.11.001.

27.

27 Novak

Mackinnon

Tung

. Patient outcome following a thoracodorsal to musculocutaneous nerve transfer for reconstruction of elbow flexion. Br J Plast Surg 2002;55 5:416–9. doi:10.1054/bjps.2002.3859.

28.

28 Oberlin

Beal

Leechavengvongs

Salon

Dauge

Sarcy

. Nerve transfer to biceps muscle using a part of ulnar nerve for C5–C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg 1994;19 2:232–7. Am. doi:10.1016/0363-5023(94)90011-6.

29.

29 Olsen

Pfeiffer

Johannsen

Schroder

Rose

. Radiation-induced brachial plexopathy: neurological follow-up in 161 recurrence-free breast cancer patients. Int J Radiat Oncol Biol Phys 1993;26 1:43–9.

30.

30 Olsen

Pfeiffer

Mondrup

Rose

. Radiation-induced brachial plexus neuropathy in breast cancer patients. Acta Oncol 1990;29 7:885–90. doi:10.3109/02841869009096384.

31.

31 Pierce

Recht

Lingos

Abner

Vicini

Silver

. Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer. Int J Radiat Oncol Biol Phys 1992;23 5:915–23.

32.

32 Posniak

Olson

Dudiak

Wisniewski

O'Malley

. MR imaging of the brachial plexus. AJR Am J Roentgenol 1993;161 2:373–9.

33.

33 Rath

Braun

Soliman

Antoniadis

Richter

. Results of DREZ coagulations for pain related to plexus lesions, spinal cord injuries and postherpetic neuralgia. Acta Neurochir (Wien) 1996;138 4:364–9. doi:10.1007/BF01420297.

34.

34 Roth

Magistris

. Neuropathies with prolonged conduction block, single and grouped fasciculations, localized limb myokymia. Electroencephalogr Clin Neurophysiol 1987;67 5:428–38. doi:10.1016/0013-4694(87)90006-X.

35.

35 Roth

Magistris

Le Fort

Desjacques

Della

. Postradiation branchial plexopathy. Persistent conduction block. Myokymic discharges and cramps. Rev Neurol (Paris) 1988;144 3:173–80.

36.

36 Roth

Rohr

Magistris

Ochsner

. Motor neuropathy with proximal multifocal persistent conduction block, fasciculations and myokymia. Evolution to tetraplegia. Eur Neurol 1986;25 6:416–23. doi:10.1159/000116045.

37.

37 Schierle

Winograd

. Radiation-induced brachial plexopathy: review. Complication without a cure. J Reconstr Microsurg 2004;20 2:149–52. doi:10.1055/s-2004-820771.

38.

38 Stoll

Andrews

. Radiation-induced peripheral neuropathy. BMJ 1966;1:834–7.

39.

39 Thomas

Colby

Jr . Radiation-induced or metastatic brachial plexopathy? A diagnostic dilemma. JAMA 1972;222 11:1392–5. doi:10.1001/jama.222.11.1392.

40.

40 Thyagarajan

Cascino

Harms

. Magnetic resonance imaging in brachial plexopathy of cancer. Neurology 1995;45 3 Pt 1:421–7.

41.

41 Tung

Mackinnon

. Brachial plexus injuries. Clin Plast Surg 2003;30 2:269–87. doi:10.1016/S0094-1298(02)00094-9.

42.

42 Tung

Novak

Mackinnon

. Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 2003;98 2:313–8.

43.

43 Tung

Weber

Mackinnon

. Nerve transfers for the upper and lower extremities. Oper Tech Orthop 2004;14:213–22. doi:10.1053/j.oto.2004.06.002.

44.

44 Westling

Svensson

Hele

. Cervical plexus lesions following post-operative radiation therapy of mammary carcinoma. Acta Radiol Ther Phys Biol 1972;11 3:209–16.

45.

45 Wittenberg

Adkins

. MR imaging of nontraumatic brachial plexopathies: frequency and spectrum of findings. Radiographics 2000;20 4:1023–32.