What is the role of nerve grafting in the treatment of spinal accessory nerve (SAN) injury?

Updated: Feb 09, 2018
  • Author: Rohan R Walvekar, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Several options are available for nerve repair when primary anastomosis will produce unacceptable tension. Grafting with nonvascularized or vascularized autologous nerves are both viable options. An example of a vascularized graft for SAN repair includes creation of a local flap in which the nerve graft is composed of the proximal sternocleidomastoid muscle and the greater auricular nerve. In this instance, the muscle and surrounding fascia provide vascularization to the nerve graft. [10]

Alternatives to autologous grafting include synthetic nerve guides or conduits. Also, nerve allografting with temporary recipient immunosuppression has been effectively used. However, autologous nerve grafting remains the criterion standard. [49]

The first description of cable grafting for repair of the SAN was reported more than 40 years ago. [14]

Immediate reconstruction of the nerve with microsurgical techniques and cable grafts can result in significant restoration of shoulder function. [52]

Cable grafts are recommended to bridge gaps greater than 2-3 cm. [41, 53]

The average size of grafts can vary from 2-5 cm. [41]

Longer intervals between injury and repair are associated with larger gaps due to nerve scarring and retraction. Longer grafts are associated with worse outcomes due to increased fiber misdirection and defective pruning. [34]

An autograft consists of a nerve segment taken from another nerve within the same patient to be interposed between the 2 cut ends of the SAN. Common donor grafts include the following:

  • Greater auricular nerve

  • Sural nerve

  • Anterior branch of the medial antebrachial cutaneous nerve

  • Lateral anti-brachial cutaneous nerve

  • Thoraco-dorsal nerve


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