Spinal Accessory Neurotization for Restoration of Elbow Flexion in Avulsion Injuries of the Brachial Plexus Panupan Songcharoen,MD, BanchongMahaisavariya,MD, Charoen Chotigavanich,MD, Bangkok,Thailand Traumatic root avulsion brachial plexus injuries in 216 patients were treated with spinal accessory-musculocutaneous neurotization to restore elbow flexion. The average postopera- tive follow-up period was 6 years, with a minimum of 2 years for all patients. The percentage of satisfactory biceps recovery (MRC II1 or better) was 72.5%. The average interval between the operation and MRC 111 motor recovery was 17 months. The percentage of poor results increased from 25.5% to 62.5% in patients who underwent operation later than 9 months after injury. This method of neurotization produces a result comparable with, if not better than, the results of other types of neurotization in restoration of elbow flexion. (J Hand Surg 1996;21A:387-390.) Tramnatic brachial plexus injury is a major health concern in many developing countries. This type of injury usually affects individuals in their productive years of life, leaving them with severe residual dis- ability. The majority of brachial plexus injuries are caused by traction secondary to motorcycle acci- dents. There is no possibility of spontaneous regener- ation or surgical repair of the avulsed nerve root after this type of injury; the only method of repair is nerve transfer or neurotization, which involves isolating an uninjured neighboring donor nerve and dividing it from its normal end organ. The nerve is then con- nected directly or by nerve grafts to a nonfunctioning nerve or implanted directly into denervated muscle. 1 Various donor nerves have been used, but few are reported to have produced a positive result. 2-u At From the Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Received for publication Feb. 3, 1995; accepted in revised form July 26, 1995. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Panupan Songcharoen, MD, Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. present, the spinal accessory and intercostal nerves are most frequently used. This article reports our experience with spinal accessory neurotization for restoration of elbow flexion in brachial plexus injury. Materials and Methods Patient Population Between 1984 and 1992, 216 patients with root avulsions underwent neurotization with the spinal accessory nerve to restore elbow flexion. All patients were treated at our hospital. The diagnosis of root avulsion was made by physical examination, electro- diagnostic studies, cervical myelography, and intra- operative findings. There were 208 male and 8 female patients, ranging in age from 4 to 58 years (average, 26 years). The postoperative follow-up period ranged from 2 to 9 years (average, 6 years). The time between injury and operation ranged from 1 to 12 months (average, 6 months). All patients sus- tained closed injuries. Motorcycle accidents caused 87% of the injuries, car accidents 8.6%, and com- pression or traction 4.4%. Complete brachial plexus paralysis was observed in 158 patients and upper arm paralysis in 58. Thelournal of Hand Surgery 387