CASE SERIES Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series Mariano Socolovsky, MD, PhD * Marcio de Mendonça Cardoso, MD ‡ Ana Lovaglio, MD * Gilda di Masi, MD * Gonzalo Bonilla, MD * Ricardo de Amoreira Gepp, MD ‡ ∗ Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; ‡ Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals, Brasilia, Brazil Correspondence: Mariano Socolovsky, MD, PhD, Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, Buenos Aires 1428, Argentina. Email: marianosocolovsky@gmail.com Received, January 3, 2020. Accepted, April 6, 2020. Copyright C  2020 by the Congress of Neurological Surgeons BACKGROUND: The phrenic nerve has been extensively reported to be a very powerful source of transferable axons in brachial plexus injuries. The most used technique used is supraclavicular sectioning of this nerve. More recently, video-assisted thoracoscopic techniques have been reported as a good alternative, since harvesting a longer phrenic nerve avoids the need of an interposed graft. OBJECTIVE: To compare grafting vs phrenic nerve transfer via thoracoscopy with respect to mean elbow strength at fnal follow-up. METHODS: A retrospective analysis was conducted among patients who underwent phrenic nerve transfer for elbow fexion at 2 centers from 2008 to 2017. All data analysis was performed in order to determine statistical signifcance among the analyzed variables. RESULTS: A total of 32 patients underwent supraclavicular phrenic nerve transfer, while 28 underwent phrenic nerve transfer via video-assisted thoracoscopy. Demographic charac- teristics were similar in both groups. A statistically signifcant diference in elbow fexion strength recovery was observed, favoring the supraclavicular phrenic nerve section group against the intrathoracic group (P = .036). A moderate though nonsignifcant diference was observed favoring the same group in mean elbow fexion strength. Also, statistical diferences included patient age (P = .01) and earlier time from trauma to surgery (P = .069). CONCLUSION: Comparing supraclavicular sectioning of the nerve vs video-assisted, intrathoracic nerve sectioning to restore elbow fexion showed that the former yielded statistically better results than the latter, in terms of the percentage of patients who achieve at least level 3 MRC strength at fnal follow-up. Furthermore, larger scale prospective studies assessing the long-term efects of phrenic nerve transfers remain necessary. KEY WORDS: Brachial plexus injury, Phrenic nerve, Elbow fexion recovery, Video-assisted thoracoscopy Operative Neurosurgery 0:1–6, 2020 DOI: 10.1093/ons/opaa163 B rachial plexus lesions are devastating and occur predominantly in young and economically active males. Most of these injuries are secondary to motorcycle accidents and have an economic burden, especially in large cities in nondeveloped countries, where this problem has become epidemic. 1 - 6 The phrenic nerve has been extensively reported to be a very powerful source of trans- ferable axons for this type of injury, 6- 10 mainly for elbow flexion recovery. The most popular ABBREVIATIONS: BMI, body mass index; MRI, magnetic resonance imaging technique used for this purpose is supraclavicular sectioning of the donor nerve and connecting it to (1) the anterior division of the superior trunk; (2) the lateral cord; (3) the musculocu- taneous nerve; or (4) biceps branches of the musculocutaneous nerve. During connection to the anterior division of the superior trunk, the use of a graft can be avoided, but not for more distal transfers (examples 2, 3, and 4, above). In recent decades, video-assisted thoraco- scopic techniques have been reported as a good alternative for elbow flexion recovery, boasting one major advantage: harvesting of the “longer” phrenic nerve allows for its direct coaptation with distal targets like the musculocutaneous OPERATIVE NEUROSURGERY VOLUME 0 | NUMBER 0 | 2020 | 1 Downloaded from https://academic.oup.com/ons/article-abstract/doi/10.1093/ons/opaa163/5851464 by guest on 29 June 2020