Is fascicular selection by nerve stimulation techniques a necessity in selective nerve transfers targeted at restoration of elbow flexion in upper brachial plexus injuries?

In the restoration of elbow flexion nerve transfers have proven to be superior to muscle or tendon transfers. Biceps and brachialis muscles, the prime elbow flexors, are innervated by musculocutaneous nerve, taking its origin from the lateral cord of brachial plexus. A variety of donor nerves of both intraplexal and extraplexal sources have been used in the neurotization of this nerve. We prefer transfer of two fascicles, one each from ulnar nerve and median nerve, directly to the biceps and brachialis motor branches. Contrary to the pervious reports now we do not use nerve stimulation while selecting the ulnar and median nerve fascicles. Twenty two patients with upper plexus (C5 and C6) injuries were treated with bifascicular nerve transfer in the period between Jan 2006 and Aug 2007. All of the patients were males in the age group 18 to 35 years and motor cycle accident was the main cause of injury. The denervation period (time interval between injury and nerve surgery) averaged 5 months. Twenty one patients restored full elbow flexion (140°); one could achieve 110° of antigravity flexion. In MRC grade 16 scored M4 while 6 scored M3. Patients with good results could lift 8 kilograms of weights. In our experience, bifascicular nerve transfer using ulnar and median nerves as donor nerves is the most reliable method of restoring elbow flexion in upper brachial plexus injuries and there is no need of fascicular selection with a nerve stimulator prior to transfer.