title: Complications of intercostal nerve transfer for brachial plexus reconstruction.
abstract: OBJECTIVE
  Although numerous publications discuss outcomes of intercostal nerve transfer for brachial plexus injury, few publications have addressed factors associated with intercostal nerve viability or the impact perioperative nerve transfer complications have on postoperative nerve function. The purposes of this study were to report the results of perioperative intercostal nerve transfer complications and to determine whether chest wall trauma is associated with damaged or nonviable intercostal nerves.
  
  
  METHODS
  All patients who underwent intercostal nerve transfer as part of a brachial plexus reconstruction procedure as a result of injury were identified. A total of 459 nerves in 153 patients were transferred between 1989 and 2007. Most nerves were transferred for use in biceps innervation, free-functioning gracilis muscle innervation, or a combination of the two. Patient demographics, trauma mechanism, associated injuries, intraoperative nerve viability, and perioperative complications were reviewed.
  
  
  RESULTS
  Complications occurred in 23 of 153 patients. The most common complication was pleural tear during nerve elevation, occurring in 14 of 153 patients. Superficial wound infection occurred in 3 patients, whereas symptomatic pleural effusion, acute respiratory distress syndrome, and seroma formation each occurred in 2 patients. The rate of complications increased with the number of intercostal nerves transferred. Nerves were harvested from previously fractured rib levels in 50 patients. Rib fractures were not associated with an increased risk of overall complications but were associated with an increased risk of lack of nerve viability. In patients with rib fractures, intraoperative nerve stimulation revealed 148 of 161 nerves to be functional; these were subsequently transferred. In patients with preoperative ipsilateral phrenic nerve palsy, the risk of increased complications was marginally significant.
  
  
  CONCLUSIONS
  Brachial plexus reconstruction using intercostal nerves can be challenging, especially if there is antecedent chest wall trauma. Complications were associated with increasing numbers of intercostal nerves transferred. Ipsilateral rib fracture was adversely associated with intercostal nerve viability; it was not significantly associated with complication risk and should not be considered a contraindication to transfer. Preoperative phrenic nerve palsy was marginally associated with the likelihood of complications but not postoperative respiratory dysfunction when associated with intercostal nerve transfer.
  
  
  METHODS
  Therapeutic IV.
authors.affiliation: Department of Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
authors.forename: Rudy
authors.initials: R
authors.lastname: Kovachevich
authors.forename: Michelle F
authors.initials: MF
authors.lastname: Kircher
authors.forename: Christina M
authors.initials: CM
authors.lastname: Wood
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Spinner
authors.forename: Allen T
authors.initials: AT
authors.lastname: Bishop
authors.forename: Alexander Y
authors.initials: AY
authors.lastname: Shin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001917:Brachial Plexus / Q000293:injuries* / Q000601:surgery*; D002648:Child; D005260:Female; D006801:Humans; D007367:Intercostal Nerves / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016067:Nerve Transfer / Q000009:adverse effects*; D010523:Peripheral Nervous System Diseases / Q000601:surgery; D010791:Phrenic Nerve; D011183:Postoperative Complications / Q000453:epidemiology; D019651:Plastic Surgery Procedures; D012189:Retrospective Studies; D055815:Young Adult