nerve fascicle transfer using a part of the c-7 nerve for ... · dorsal approach. currently, except...

LABORATORY INVESTIGATIONJ Neurosurg Spine 28:555–561, 2018

Spinal accessory nerve (SAN) injury leads to loss of control over the sternocleidomastoid muscle (SCM) and the trapezius muscle, the major shoulder stabi-

lizer, and results in a series of shoulder dysfunctions—for example, obvious droop of shoulder, significant limitation of shoulder abduction, and continuous shoulder pain. Re-cent research has identified the 3 main branching types of SAN, showing a high occurrence of anatomical varia-

tions.10 Additionally, because the SAN runs superficially through the posterior triangle, lymph nodes are generally found adjacent to its course. Due to the closeness of these important anatomical structures, SAN injury is not rare and can occur at any level of its course. Iatrogenic injury caused by cervical lymph node dissection is the most fre-quent cause.5 Although techniques for radical node dis-section and function node dissection have been designed,

ABBREVIATIONS EMG = electromyography; MUAP = motor unit action potential; NFT = nerve fascicle transfer; PD = posterior division; SAN = spinal accessory nerve; SCM = sternocleidomastoid muscle. SUBMITTED May 21, 2017. ACCEPTED August 16, 2017.INCLUDE WHEN CITING Published online February 9, 2018; DOI: 10.3171/2017.8.SPINE17582.* X.Y. and Y.D.S. contributed equally to this work.

Nerve fascicle transfer using a part of the C-7 nerve for spinal accessory nerve injury*Xuan Ye, MD,1 Yun-Dong Shen, MD, PhD,1 Jun-Tao Feng, MD,1 and Wen-Dong Xu, MD, PhD1–3

1Department of Hand Surgery, Huashan Hospital, Shanghai Medical College, Fudan University; 2Department of Hand and Upper Extremity Surgery, Jing’an District Central Hospital; and 3State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China

OBJECTIVE Spinal accessory nerve (SAN) injury results in a series of shoulder dysfunctions and continuous pain. However, current treatments are limited by the lack of donor nerves as well as by undesirable nerve regeneration. Here, the authors report a modified nerve transfer technique in which they employ a nerve fascicle from the posterior division (PD) of the ipsilateral C-7 nerve to repair SAN injury. The technique, first performed in cadavers, was then undertaken in 2 patients.METHODS Six fresh cadavers (12 sides of the SAN and ipsilateral C-7) were studied to observe the anatomical relation-ship between the SAN and C-7 nerve. The length from artificial bifurcation of the middle trunk to the point of the poste-rior cord formation in the PD (namely, donor nerve fascicle) and the linear distance from the cut end of the donor fascicle to both sites of the jugular foramen and medial border of the trapezius muscle (d-SCM and d-Traps, respectively) were measured. Meanwhile, an optimal route for nerve fascicle transfer (NFT) was designed. The authors then performed successful NFT operations in 2 patients, one with an injury at the proximal SAN and another with an injury at the distal SAN.RESULTS The mean lengths of the cadaver donor nerve fascicle, d-SCM, and d-Traps were 4.2, 5.2, and 2.5 cm, re-spectively. In one patient who underwent proximal SAN excision necessitated by a partial thyroidectomy, early signs of reinnervation were seen on electrophysiological testing at 6 months after surgery, and an impaired left trapezius muscle, which was completely atrophic preoperatively, had visible signs of improvement (from grade M0 to grade M3 strength). In the other patient in whom a distal SAN injury was the result of a neck cyst resection, reinnervation and complex repeti-tive discharges were seen 1 year after surgery. Additionally, the patient’s denervated trapezius muscle was completely resolved (from grade M2 to grade M4 strength), and her shoulder pain had disappeared by the time of final assessment.CONCLUSIONS NFT using a partial C-7 nerve is a feasible and efficacious method to repair an injured SAN, which provides an alternative option for treatment of SAN injury.https://thejns.org/doi/abs/10.3171/2017.8.SPINE17582KEY WORDS spinal accessory nerve; C-7 nerve; posterior division; nerve fascicle transfer; anatomy

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there remains a 5.1% complication rate for SAN injury, just lower than that for mandibular nerve injury (5.5%).2,3 Additionally, lymph node biopsy and thyroid surgery are the other causes of SAN injury with an intractable high incidence rate.14,15 Kim et al.9 reported a 2.3% probability of SAN injury in ultrasonography-guided radiofrequency ablation for recurrent thyroid cancers, and Schardey et al.17 observed that 1 of 28 patients (3.3%, with 30 sides in total) suffered from temporary SAN paralysis after undergoing the “EndoCATS,” an endoscopic surgery via an improved dorsal approach. Currently, except for in situ nerve suture and autogenous nerve grafting, the most widely used treat-ment is nerve transfer; the posterior division (PD) of the C-7 nerve, lateral pectoral nerve, and even long thoracic nerve were once harvested as nerve donors.12,18 Further-more, when the aforementioned techniques cannot be em-ployed, tension reconstructions can be considered.4,16

However, when standard treatment—repair with an interpositional graft—is impossible in such conditions as high-level injury, methods are limited because of the unavailability of the proximal SAN. In this study, we de-scribe a feasible surgical procedure in which nerve fas-cicle transfer (NFT) is performed by using a nerve fascicle

from the PD of the ipsilateral C-7 nerve to repair an in-jured SAN, and we evaluate the efficacy of the technique postoperatively. The technique, first performed in cadav-ers, was then undertaken in two patients.

MethodsApplied Anatomical Study

Six fresh adult cadavers (4 males and 2 females; age range at death 50–65 years) were dissected (Fig. 1). The SAN was explored carefully from the jugular foramen to the medial border of the trapezius muscle, and the bra-chial plexus was also explored from the intervertebral fo-ramen to its divisions. We measured the length of donor nerve fascicle from artificial bifurcation (the site that C-7 gives off the fascicle) of the middle trunk to the posterior cord formation point at the PD (Fig. 2). After the fascicle was cut at the point of posterior cord formation, the lin-ear distance between the cut end and the major trunk of the SAN at the jugular foramen and the cut end and the muscle entry point of the SAN at the medial border of the trapezius muscle were both measured. Finally, models of the SAN injury at different levels were simulated, and we performed end-to-end anastomoses without tension via

FIG. 1. Photographs of the surgical technique designed in fresh cadavers. A: The course of the SAN in the anterior and posterior triangle and the brachial plexus in the supraclavicular space. B: A fascicle of suitable size (asterisk) was divided from the PD of the middle trunk. C and D: The cut end of the fascicle was moved to an appropriate site, and the SAN was mobilized simultaneously. Then, tension-free, end-to-end suturing was performed. AD = anterior division; d-SCM = distance from the cut end of the fascicle to the jugular foramen; d-Traps = distance from the cut end of the fascicle to the trapezius muscle entry site of the SAN; l-fascicle = length between artificial bifurcation of the middle trunk and the cut end of the fascicle. Figure is available in color online only.


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a supraclavicular approach. All anatomical studies were carried out in the Anatomy Dissection Hall of Fudan Uni-versity, and an expert anatomist completed the dissection of all these cadavers.

Surgical Technique in PatientsAfter achieving satisfactory general anesthesia and

disinfection, the NFT was performed through a supracla-vicular incision (Fig. 2). The injured SAN, which might be damaged at any level with different severities, should be explored first, and the distal accessory nerve should be identified in the primary injury site of the neck. At this point, a corresponding incision and a suitable approach were crucial in this step to clearly find our target nerve. Then, a traditional approach—a transverse supraclavicular incision of approximately 8 cm—was used to reveal the ip-silateral brachial plexus. Under protection of the external jugular vein, the omohyoid muscle was pulled obliquely upward, and the anterior scalene muscle was seen directly as well was its superficial-lying nerve, the phrenic nerve. The C-5 and C-6 nerve roots behind the posterior border of the anterior scalene muscle could be identified. Next, dissection was extended distally so that the PD of the C-7 nerve could be traced to the point of the posterior cord formation, during which ligation of the transverse cervical artery was allowed, if necessary. After intraoperative elec-tromyography (EMG) confirmation, the PD of the middle trunk was carefully dissected into 2 beams under micro-

scopic magnification. The dorsal beam, which had a favor-able size with the distal stump of the injured SAN and mainly dominated the extensor muscle group (the ventral one mainly controlled the latissimus dorsi muscle; both were verified by intraoperative EMG), was chosen and dis-sected proximally in favor of coordinated movement be-tween shoulder abduction and forearm stretch. This thin-ner targeted fascicle was then transected at the point of the posterior cord formation and moved upward, or outward, to an appropriate location. At the same time, the distal end of the paralyzed SAN was transferred toward the target-ed fascicle so that the 2 stumps could meet in the same place. Finally, end-to-end nerve anastomoses without ten-sion were performed microscopically with 10-0 Prolene through a subcutaneous tunnel. The incision was closed, and the patient was fitted with a head-arm orthosis postop-eratively. The affected upper limb was immobilized strict-ly with the shoulder in adduction and the elbow in 90° flexion. After 1 month, the external fixation apparatus was removed, and the patient was encouraged to gradually in-crease activity of the affected upper extremity. When early reinnervation signs appeared (approximately 6 months af-ter surgery), intensive rehabilitation was initiated.13

Clinical ApplicationCase 1

This 19-year-old man, who found that the left side of

FIG. 2. Schematic of the ipsilateral C-7 NFT to the SAN. A fascicle of suitable length from the PD to the middle trunk is transferred to an appropriate location for suturing with the injured distal SAN without tension. l-f = l-fascicle (length between the artificial bifur-cation of the middle trunk and the cut end of the fascicle); MT = middle trunk; X = point of artificial origin of the fascicle; Y = point where the PDs of the upper, middle, and inferior trunks merge to form the posterior cord. Copyright Wen-Dong Xu. Published with permission. Figure is available in color online only.


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his neck had gradually become swollen, was diagnosed with a thyroid cyst in January 2016. An exploratory op-eration on the left side of the neck was performed, and a huge mass adhering to his left lobe of the thyroid was identified. In consideration of the potential for recurrence, an extensive local excision was performed, although the postoperative pathological examination showed the lesion was benign. Unfortunately, the main trunk of the SAN was unintentionally transected intraoperatively. Immedi-ately after surgery, the patient felt shoulder discomfort. Soon after, the trapezius muscle started to become atro-phic, leading to an obvious restriction in the movement of his left shoulder as well as tolerable pain. After nearly 7.5 months, he underwent the NFT operation (Fig. 3E–G), at which time his trapezius muscle had become completely atrophic (Fig. 3A); his shoulder abduction was up to 30° with the help of the ipsilateral deltoid muscle.

Case 2This 52-year-old woman found a lump on the right side

of her neck but experienced no unpleasant symptoms. She consulted her general physician and underwent a radical resection of the mass in August 2015. Unfortunately, she immediately realized that her right upper limb was unable to abduct postoperatively, and she experienced severe and continuous pain in her right shoulder, which could not be accurately positioned. Approximately 2 months after the partial thyroidectomy, the NFT procedure (Fig. 4E–G) was performed with shoulder abduction up to 30° and ex-cruciating pain at that time.

ResultsIn anatomical studies, SANs were found bilaterally in

all specimens, and all these observations were recorded as follows (Table 1). The length of the fascicles ranged from 3.8 to 4.5 cm, with a mean of 4.2 cm and a standard deviation of 0.22. The distance from the cut end of the fascicles to the jugular foramen ranged from 4.5 to 6.0 cm, with a mean of 5.2 cm and a standard deviation of

FIG. 3. Case 1. A: Radical impairment of the SAN and complete atrophy of the left trapezius muscle can be seen preopera-tively. B: Nine months after surgery, although slight atrophy remains, the left trapezius muscle has greatly improved in terms of muscle fullness and shrugging power. C and D: Twelve months after surgery, shoulder abduction and the ability to raise the upper limbs straight up were demonstrated, with a slightly winged left shoulder. The patient was asked to raise his upper limb while he lay in the prone position, which is a special test to examine the power of the trapezius muscle (upper left in C [arrow] and upper right). E: Exploration of the injured left SAN beneath a nasty scar and the PD of the middle trunk. F: The SAN was traversed at an upper level, and the distal stump was mobilized downward, close to the brachial plexus. The fascicle divided from the C-7 nerve had not yet been cut off. G: Intraoperative view of the coaptation site between the fascicle and the SAN through a subcutaneous tunnel of the neck. Asterisk in F and G indicates the fascicle divided from the PD of the ipsilateral C-7 nerve. Figure is available in color online only.



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0.46. The distance from the cut end of the fascicles to the trapezius muscle entry site of the SAN ranged from 2.0 to 3.0 cm, with a mean of 2.5 cm and a standard deviation of 0.37. Tension-free end-to-end neurorrhaphies between the SANs and donor fascicles were successfully performed on all sides (Fig. 1C and D).

At present, the patient in case 1 has undergone follow-up for 1 year postoperatively (Fig. 3B–D). In the first 6 months after surgery, nascent motor unit action potentials (MUAPs) were present in both the SCM and the trapezius

muscle with shoulder abduction up to 90°. At 9 months, the atrophy and myodynamia of the trapezius muscle im-proved significantly. The creation of wrinkles on the left side of the neck indicated obvious improvement in the pa-tient’s ability to shrug (Fig. 3B). At the most recent follow-up (12 months), bilateral testing was performed to confirm the function of the trapezius muscle, and the hallmark contraction of the trapezius muscle was clearly shown (Fig. 3C upper left and upper right). With the favorable recovery of the trapezius muscle and the compensation of

FIG. 4. Case 2. A and B: Postoperative photographs obtained 1 year after the procedure. Muscle fullness of the right-sided trapezius muscle was significantly restored. C and D: Photographs obtained 1.5 years after surgery. Both shoulder abduction and the ability to raise the upper limbs straight up were achieved without difficulty or pain. E: Dissection of the right-sided injured SAN and targeted fascicle from the middle trunk via the same incision. F: The distal stump of the SAN was swung forward and sutured directly with the fascicle. G: Intraoperative view of the coaptation. Asterisk in F and G indicates the targeted fascicle from the PD of the C-7 nerve. Figure is available in color online only.

TABLE 1. Summary of measurements obtained in 6 cadavers

MeasurementCadaver No. (sex)

Mean ± SD1 (M) Rt/Lt 2 (M) Rt/Lt 3 (M) Rt/Lt 4 (M) Rt/Lt 5 (F) Rt/Lt 6 (F) Rt/Lt

l-fascicle 4.0/3.8 4.0/4.0 4.0/4.2 4.4/4.5 4.1/4.2 4.3/4.5 4.2 ± 0.22d-Traps 3.0/2.6 2.8/3.0 2.5/2.0 2.0/2.4 2.2/2.5 2.0/2.7 2.5 ± 0.37d-SCM 6.0/5.8 5.0/5.4 5.8/5.0 4.8/5.0 5.0/5.0 4.5/5.0 5.2 ± 0.46

d-SCM = linear distance between the stump of the donor fascicle to the jugular foramen; d-Traps = linear distance between the stump of the donor fascicle to the medial border of the trapezius muscle; l-fascicle = length between the artificial bifurcation of the middle trunk and the cut end of the fascicle.Values are presented in centimeters.


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the deltoid muscle, the patient was able to abduct as well as raise his left upper extremity straight up without pain (Fig. 3C lower and D). His daily life was normal.

The patient in case 2 was followed up for 18 months. Her shoulder pain was completely relieved within 3 months. At 6 months after surgery, EMG revealed evidence of na-scent MUAPs in the right trapezius muscle. After 1 year, atrophy of the right trapezius muscle was significantly improved, and its strength frankly improved (Fig. 4A and B), and these results corresponded with her EMG findings. After 1.5 years, there were no visible differences between either shoulder with respect to profile and strength (Fig. 4C and D). The patient was able to return to her previous jobs, with her right shoulder functioning well.

More detailed information and data are summarized in Table 2.

DiscussionPrevious studies6,11 have demonstrated some clinical

cases in which the patients recovered well after undergo-ing nerve transfer that involved using a partial component of the middle trunk or C-7 nerve root. In the current report, we establish an improvement in technique based on anat-omy studies. The same operation, NFT, was performed in 2 patients. The patient in case 1 had a proximal lesion that resulted from thyroid disease. His trapezius muscle and SCM were impaired, and the injured nerve, buried in scar tissue, was hard to locate. In case 2 the injury was iatrogenic, at the distal SAN, and the patient experienced serious shoulder pain. NFT was successfully performed in both patients, and each patient made an excellent recovery during the follow-up period.

Another inspiring study of nerve transfer for SAN in-jury was published by Maldonado and Spinner12 in 2017. They described 2 patients in whom typical SAN injury was confirmed, the same treatment with nerve transfer using the ipsilateral lateral pectoral nerve was used, and

favorable outcomes shown in examinations were con-ducted during a lengthy follow-up period. However, the authors admitted that secondary reconstruction using ten-sion transfers should be considered when reinnervation is impossible due to long-term SAN injury or unsuccessful nerve repair. We appreciate the technique presented by Maldonado and Spinner; both their procedure and ours are effective and can be performed using a supraclavicular ap-proach without iatrogenic injury of the ipsilateral healthy upper limb. A distinction should be made as follows. First, the lateral pectoral nerve has many variants and most commonly arises from the anterior division of the upper trunk, with an origin distinctly proximal (mean 24.7 ± 9.8 mm) to the lateral cord, while C-7 and its PD run with a better location closer to the SAN.1 Hence, transfer by mo-bilizing a partial C-7 nerve could be easier via a standard supraclavicular incision (instead of a linear incision just above the inferior edge of the clavicle). Second, the size of the C-7 nerve is categorically large enough compared with the lateral pectoral nerve, which has been supported by our previous anatomical work. We have found that the mean number of motor fibers in the main trunk of the lat-eral pectoral nerve was 3260 ± 537 (mean ± SD); however, this number was less than that seen in the PD of the C-7 nerve.20 Third, when the SAN has been damaged in the middle of its course, both methods are available for repair. However, nerve transfer using a partial C-7 nerve might be more feasible when the injury is proximal to the jugular foramen, since the fascicle from the PD of the C-7 nerve is longer in length and closer to the SAN.

In summary, compared with previously reported pro-cedures, our method has the following advantages. 1) The technique is designed based on the findings that the long-term function of the ipsilateral limb will not be affected when the C-7 nerve root is cut off.7,8 According to histo-chemical and clinical observations, transfer using a partial C-7 nerve is safe and feasible, and the motor nerve fibers in the PD (approximately 4155 ± 1063) are more abundant than they are in the major trunk of the SAN (mean 1933 ± 377, at the level of the hyoid bone).19,21–23 2) The fascicle from the PD of C-7 is superior to that of its trunk or root. It is generally accepted that regeneration in a motor-to–mo-tor nerve transfer is better than that of motor-to–sensory or motor-to–mixed nerve transfer. Xu et al.21 have shown that the PD of C-7 contains more motor fibers than the an-terior division (34.4% ± 2.9% vs 15.3% ± 0.6%). Addition-ally, the proportion of motor fibers was shown not to differ significantly between lateral and medial parts of the PD. Thus, we posit that any bundle of nerve fascicles divided from the PD could have similar optimum regeneration, which was underscored by the favorable outcomes of our patients. 3) This procedure is relatively easy to carry out as long as careful exploration of the distal injured SAN is performed. Because of the short distance between the C-7 nerve and the SAN and their similar course, a direct repair without nerve graft can be achieved via a single incision; additionally, a faster recovery can be expected when using a single-suture junction. 4) Most importantly, the length of the target fascicle is long enough for tension-free su-ture when dissection is extended proximally to the middle trunk. The data related to the 2 key measurements (the

TABLE 2. Shoulder function before and after the NFT procedure

Variable

Case 1 Case 2

Preop6 Mos Postop Preop

1 Yr Postop

Severity of pain Controllable None Severe NoneTraps atrophy ++++ ++ +++ –Shrug strength

gradeM0 M3 M2 M4

Shoulder AA 30° 90° 30° 160°EMG finding Fibs Yes Yes Yes No Pos waves Yes Yes Yes No Recruitment No MUAPs

or CMAPsIncreased MUAPs

No MUAPs or CMAPs

CRDs

Satisfaction Good Excellent

AA = abduction angle; CMAP = compound muscle action potential; CRD = complex repetitive discharge; Fib = fibrillation potential; Pos waves = positive sharp waves; Traps = trapezius muscle; Traps atrophy (from – to ++++) = none, slight, moderate, marked, complete.



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length from artificial bifurcation of the middle trunk to the point of the posterior cord formation in the PD [namely, the donor nerve fascicle] and the linear distance from the cut end of the donor fascicle to both sites of the jugular fo-ramen and the medial border of the trapezius muscle) were collected with an eye toward guiding surgeons in deter-mining the possibility of tension-free suture during surgi-cal exploration. This technique could benefit most patients with injury at the proximal or distal SAN, reducing the number of suffering patients who are preparing for salvage operations of tendon transfer. 5) Finally, we propose that the significant shoulder pain relief that occurred within 3 months after surgery could be a postoperative benefit shared by others treated with NFT.

ConclusionsStandard approaches should be direct nerve coaptation

in situ when both proximal and distal ends of the SAN are available and of suitable length for suturing directly, or for a nerve graft when there is a slight nerve deficit be-tween both stumps of the SAN. Otherwise, nerve trans-fer is the optimal choice, e.g., partial C-7 nerve transfer. Overall, once an SAN injury is suspected, early diagnosis and appropriate management are crucial in restoration of shoulder function. The technique of NFT using a part of the C-7 nerve can be considered in most cases without an interpositional graft in good condition, and the prognosis is always better with a timely treatment.

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sites of origin of the suprascapular and lateral pectoral nerves within the brachial plexus. Plast Reconstr Surg 133:20e–27e, 2014

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6. Goubier JN, Teboul F: Partial transfer from C7 root to exter-nal branch of accessory nerve for trapezius palsy. Hand Surg Rehabil 35:418–419, 2016

7. Gu YD, Chen DS, Zhang GM, Cheng XM, Xu JG, Zhang LY, et al: Long-term functional results of contralateral C7 trans-fer. J Reconstr Microsurg 14:57–59, 1998

8. Gu YD, Shen LY: Electrophysiological changes after sever-ance of the C7 nerve root. J Hand Surg [Br] 19:69–71, 1994

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15. Roerink SH, Coolen L, Schenning ME, Husson O, Smit JW, Marres HA, et al: High prevalence of self-reported shoulder complaints after thyroid carcinoma surgery. Head Neck 39:260–268, 2017

16. Satbhai NG, Doi K, Hattori Y, Sakamoto S: Contralateral lower trapezius transfer for restoration of shoulder external rotation in traumatic brachial plexus palsy: a preliminary report and literature review. J Hand Surg Eur Vol 39:861–867, 2014

17. Schardey HM, Barone M, Pörtl S, von Ahnen M, von Ahnen T, Schopf S: Invisible scar endoscopic dorsal approach thyroidectomy: a clinical feasibility study. World J Surg 34:2997–3006, 2010

18. Sun J, Li J, Jiang J: [Transpositional anastomosis of C7 pos-terior root and spinal accessory nerve to reconstruct the tra-pezius muscle function.] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 19:890–893, 2005 (Chinese)

19. Wang C, Zhang Y, Nicholas T, Wu G, Shi S, Bo Y, et al: Neurotization of the phrenic nerve with accessory nerve for high cervical spinal cord injury with respiratory distress: an anatomic study. Turk Neurosurg 24:478–483, 2014

20. Wang S, Zhang G, Zhao X, Zhang L, Gu Y: The applied anatomical study of the contralateral lateral pectoral nerve transfer to reconstruct the brachial plexus injury. Chin J Mi-crosurg 23:47–49, 2000

21. Xu J, Hu S, Wang H, Gu Y: Histochemical study on C7 roots and its clinical significance. Chin J Clin Anat 14:243–245, 1996

22. Xu JG, Gu YD, Hu SN, Wang H, Chen L: Electrophysiologic study of influence on C7 innervated muscles after transection of different C7 fascicles. Microsurgery 24:147–150, 2004

23. Xu JG, Gu YD, Wang H, Hu SN, Yong Chen Z: Comparative experimental study on treatment outcome of nerve transfer, using selective C7 nerve root vs. phrenic nerve. Microsur-gery 24:143–146, 2004

DisclosuresThe authors report no conflict of interest concerning the materi-als or methods used in this study or the findings specified in this paper.

Author ContributionsConception and design: Xu. Acquisition of data: Ye, Shen, Feng. Analysis and interpretation of data: Ye, Shen. Drafting the article: Ye. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Xu. Study supervision: Xu.

CorrespondenceWen-Dong Xu: Fudan University, Shanghai, China. [email protected].


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