title: Correlation between histopathological findings in C-5 and C-6 nerve stumps and motor recovery following nerve grafting for repair of brachial plexus injury.
abstract: OBJECTIVE
  Proximal spinal nerve stumps were used as donor sites for grafts to repair brachial plexus traction lesions. The quality of the stumps was assessed histologically, and its correlation with the strength attained in the target muscle was studied.
  
  
  METHODS
  Four histopathological parameters in frozen tissue sections of 31 C-5 or C-6 nerve stumps were examined by a neuropathologist. The total quantity of myelin was compared with normal values. Also, thick myelinated fibers, fibrosis, and misdirected axons were assessed. Stumps embedded in plastic were used in a morphometric study of myelinated fiber profiles. The fiber density, mean size, and size distribution in five donor stumps were determined; three normal C-5 spinal nerves obtained at autopsy served as controls. Finally, the relative area occupied by fiber profiles and interspace was computed. Linear regression was used as a multivariate analysis, adjusting the outcome of surgical repair for effects of age, interval between trauma and surgery, and graft length. Histopathological examination showed that the total quantity of myelin in donor stumps used for biceps muscle reinnervation was considerably reduced. On morphometric examination the fiber density did not differ significantly between stumps obtained in patients and control stumps obtained at autopsy. However, a significant reduction of the area occupied by myelinated fibers was measured: from 46% in controls to 13% in patients (p < 0.0001). Likewise, a significant reduction was found in the mean fiber size: from 7.4 microm in controls to 3.7 microm in patients (p < 0.0001). The relationship between the myelin quantity in the proximal stump and the grade of biceps muscle recovery was statistically significant (p = 0.02). From the 95% confidence interval it was concluded that the estimated effect of a mean increase of myelinated fibers by 25% almost equals an increase in recovery of one point on the Medical Research Council scale (grade range 0-5).
  
  
  CONCLUSIONS
  Both histopathological and morphometric examination showed a reduction of the quantity of myelin in C-5 or C-6 stumps used as donor sites for grafts. The amount of myelin is significantly correlated with biceps muscle function after nerve grafting. Because it is possible to assess the quantity of myelin by intraoperative examination of frozen sections, this correlation is potentially useful in the decision-making process of whether to use stumps for grafting or to use nerve transfer procedures to restore biceps muscle function.
authors.affiliation: Department of Neurosurgery, Leiden University Medical Center, The Netherlands.
authors.forename: M J
authors.initials: MJ
authors.lastname: Malessy
authors.forename: S G
authors.initials: SG
authors.lastname: van Duinen
authors.forename: H K
authors.initials: HK
authors.lastname: Feirabend
authors.forename: R T
authors.initials: RT
authors.lastname: Thomeer
mesh_terms: D000293:Adolescent; D000328:Adult; D001132:Arm; D001917:Brachial Plexus / Q000293:injuries*; D006801:Humans; D018482:Muscle, Skeletal / Q000294:innervation* / Q000503:physiopathology / Q000601:surgery*; D009186:Myelin Sheath / Q000473:pathology; D009333:Neck; D009413:Nerve Fibers, Myelinated / Q000473:pathology; D009417:Nerve Tissue / Q000637:transplantation*; D011184:Postoperative Period; D012189:Retrospective Studies; D013127:Spinal Nerves / Q000473:pathology / Q000503:physiopathology* / Q000637:transplantation*; D014947:Wounds and Injuries / Q000601:surgery*