A modified longitudinally split segmental rectus femoris muscle flap transfer for facial reanimation: Anatomic basis and clinical applications

The present study was conducted to investigate the intra-muscular neurovascular anatomy and the intra-muscular tendon distribution of the rectus femoris muscle to reassess the reliability of technique of harvesting a longitudinally split segmental muscle flap, and to present our clinical experience on usefulness of the longitudinally split segmental rectus femoris muscle flap as a method for reconstruction of the paralysed face in a series of 25 patients. Twenty fresh cadavers were systemically injected with lead oxide, gelatin and water. Based on the anatomy of intra-muscular neurovascular structure in the rectus femoris muscle, 25 consecutive patients with established facial paralysis were treated by using a two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting. Follow-ups were 15-24 months. All of the 25 patients showed significantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases having poor movement of transferred muscle 2 years postoperatively. No complications occurred in the donor site. In conclusion, the present study has demonstrated the suitability for subdivision of the segment muscle flap of the rectus femoris into two functional units with a common neurovascular pedicle. This series has further demonstrated the safety and reliability of using the rectus femoris muscle flap for facial reanimation.

End-to-side nerve coaptation: a qualitative and quantitative assessment in the primate

There are several reasons why end-to-side nerve coaptation has not been widely adopted clinically. Among these are the putative damage inflicted on the donor nerve and the variable quality of the regeneration in the recipient nerve. So far experiments on end-to-side nerve repair have been short term and mostly carried out on rats. This long-term study of end-to-side nerve repair of ulnar to median and median to ulnar nerve was performed using adult nonhuman primates. Eleven nerve repairs were studied at different time points. Eighteen, 22, 33 and 57 months after surgery a qualitative and quantitative analysis of the donor nerve and regenerating nerve revealed variable levels of percentage axonal regeneration compared with matched controls (1.4%-136%). Morphological evidence of donor nerve damage was identified distal to the coaptation site in four of the 11 cases, and in these cases the best axonal regeneration in the corresponding recipient nerves was observed. This donor nerve damage could neither be demonstrated in terms of a decrease in axon counts distal to the coaptation nor as donor target organ denervation. Recipient target organ regeneration like the axonal regeneration varied, with evidence of motor regeneration in eight out of 11 cases and sensory regeneration, as measured by percentage innervation density compared with matched controls, varied from 12.5% to 49%. Results from the present study demonstrate that the end-to-side coaptation technique in the nonhuman primate does not give predictable results. In general the motor recovery appeared better than the sensory and in those cases where donor nerve damage was observed there was better motor and sensory regeneration overall than in the remaining cases.

Neuronal survival, regeneration and musclemorphology after posterior C7 nerve transfer:An experimental study

C7 nerve transfer has been widely used in treating brachial plexus avulsion injuries. Little is known regarding the survival and regeneration of C7 motor and sensory neurons including their morphological changes after this procedure and also the possible change of muscle fibre phenotype. In this experimental study, the posterior division of C7 nerve was transferred to the musculocutaneous nerve ipsilaterally, and using fluorescent tracing techniques, the C7 spinal cord segment and dorsal root ganglion were found to contain 630.9 +/- 86.7 motor neurons and 3916.0 +/- 517.3 sensory neurons, respectively. Six months following transfer, 90% of the motor neurons and 78% of the sensory neurons survived and approximately 40% of them had regenerated and all displayed normal soma size. After posterior C7 transfer and reinnervation, the target muscles showed a percentage pattern of distribution and mean fibre diameters similar to those seen in normal biceps muscle. The present study suggests that the posterior C7 nerve transfer provides sufficient number of neurons and satisfactory results for regeneration to obtain an acceptable functional recovery.

Transarticular repair of the brachial plexus. Case report

This paper illustrates the repair of a complex and unusually placed iatrogenic injury of the brachial plexus. The authors present the case of a 36-year old woman, musician (piano solista), with a dumbbell tumour of the brachial plexus. A general surgeon performed a gross total removal of the tumour, cutting it flush with the exit of the neuroforamen and this resulted in a severe upper brachial plexus injury. Four months later, the brachial plexus was repaired with a nerve graft, using a double extraforaminal and preforaminal approach via the transarticular route. The surgical procedure proved to be effective and without significant consequences for the patient.

Vascularized ulnar nerve graft

The purpose of this article is to describe the indications, anatomy, and harvesting technique of vascularized ulnar nerve graft based on the superior ulnar collateral artery (SUCA) for reconstruction of upper extremity function. The ulnar nerve has an extrinsic blood supply consisting of multiple dominant systems: the SUCA, the inferior ulnar collateral artery, the posterior ulnar recurrent artery, and the ulnar artery. The entire length of the ulnar nerve can survive based on the SUCA and its venae comitantes. The vascularized ulnar nerve graft is used when there is a hopeless prognosis for ulnar nerve repair. This technique may be selected if there is a definite evidence of preganglionic injuries of the C8 and T1 roots in brachial plexus injuries. This technique can be recommended for reconstruction of a large defect of the median or radial nerves in selected cases, such as upper arm replantation.

Anatomical and functional connectivity of the transected ulnar nerve after accessory nerve neurotization in the cat

AIM

The objective of this experimental study was to test the capacity of accessory nerve motoneurons to innervate muscles of the ulnar nerve territory after direct anastomosis.

METHODS

This study used 22 cats in two groups: experimental group (15 cats) and control group (7 cats). The first one was followed during twelve months using electromyographic records every two months postsurgery; muscle and nerve histological assessment and counting horseradish peroxidase-labeled motoneurons.

RESULTS

Our results showed that reinnervation was achieved in 12/15 nerves. The number of HRP labelled medullar motoneurons after anastomosis showed a significant statistic difference with a simple ulnar nerve transection; there was no significant statistic difference in labelling between the group with an anastomosis and the one with a simple accessory nerve transection.

CONCLUSIONS

Direct anastomosis between the spinal accessory nerve and the ulnar nerve is achievable and thus, the accessory spinal nerve is another possible choice for correcting the motor deficit arising from lower brachial plexus avulsion, but the limited number of motoneurons would only allow partial reinnervation..

Restoration of shoulder abduction by transfer of the spinal accessory nerve to suprascapular nerve through dorsal approach: a clinical study

BACKGROUND

In recent years, transfer of the spinal accessory nerve to suprascapular nerve has become a routine procedure for restoration of shoulder abduction. However, the operation via the traditional supraclavicular anterior approach often leads to partial denervation of the trapezius muscle. The purpose of the study was to introduce transfer of the spinal accessory nerve through dorsal approach, using distal branch of the spinal accessory nerve, to repair the suprascapular nerve for restoration of shoulder abduction, and to observe its therapeutic effect.

METHODS

From January to October 2003, a total of 11 patients with a brachial plexus injury and an intact or nearly intact spinal accessory nerve were treated by transferring the spinal accessory nerve to the suprascapular nerve through dorsal approach. The patients were followed up for 18 to 26 months [mean (23.5 +/- 5.2) months] to evaluate their shoulder abduction and function of the trapezius muscle. The outcomes were compared with those of 26 patients treated with traditional anterior approach. And the data were analyzed by Student's t test using SPSS 10.5.

RESULTS

In the 11 patients, the spinal accessory nerves were transferred to the suprascapular nerve through the dorsal approach successfully. Intact function of the upper trapezius was achieved in all of them. In the patients, the location of the two nerves was relatively stable at the level of superior margin of the scapula, the mean distance between them was (4.2 +/- 1.4) cm, both the nerves could be easily dissected and end-to-end anastomosed without any tension. During the follow-up, the first electrophysiological sign of recovery of the infraspinatus appeared at (6.8 +/- 2.7) months and the first sign of restoration of the shoulder abduction at (7.6 +/- 2.9) months after the operation, which were earlier than that after the traditional operation [(8.7 +/- 2.4) months and (9.9 +/- 2.8) months, respectively; P < 0.05]. The postoperative shoulder abduction was 62.8 degrees +/- 12.6 degrees after transfer of the spinal accessory nerve, better than that after the traditional (51.6 degrees +/- 15.7 degrees). All the 11 patients could extend and externally rotate the shoulder almost normally.

CONCLUSIONS

The accessory nerve transfer through dorsal approach is a safe and reliable procedure for the treatment of brachial plexus injury. Its postoperative effect is confirmed, which is better than that of the traditional operation.

[Anatomic study of the hypoglossal nerve in hypoglossal-facial nerve anastomosis]

OBJECTIVE

To determine the optimal position of hypoglossal nerve in hypoglossal-facial nerve anastomosis and the eligibility of hypoglossal-facial nerve anastomosis with the cervical loop.

METHODS

The cervical course and adjacent structures of the hypoglossal nerve were observed on 21 adult cadavers. The hypoglossal nerve and facial nerve were taken from 3 fresh specimens, and the number of the fasciculus and the cross-sectional area of the nerve were measured.

RESULTS

The facial nerve trunk were monofascicular with a cross-sectional area of 5.1-/+0.2 (range 4.6-5.7) mm(2). The number of the fasciculus and the cross-sectional areas of the nerve trunk and the fasciculus were 1.6-/+0.8 (range 1-4) mm(2) , 7.5-/+0.7 mm(2) (range 6.8-8.0) mm(2), and 4.7-/+0.6 (4.1-5.5) mm(2), respectively, at the proximal segment of the hypoglossal nerve, 3.6-/+0.5 (1-5) mm(2) , 5.6-/+0.5 (4.9-6.1) mm(2) , and 1.6-/+0.4 (0.9-2.2) mm(2) at the distal segment, and 2.4-/+0.8 (1-3) mm(2), 1.1-/+0.7 (0.6-2.2) mm(2), and 0.5-/+0.3 (0.3-1.2) mm(2) at the cervical loop.

CONCLUSION

The cervical loop is inadequate for facial nerve anastomosis and the proximal segment is large enough to allow partial harvesting of the hypoglossal nerve for neurotisation of the facial nerve.

Hypoglossal nerve transfer in obstetric brachial plexus palsy

A cost-benefit analysis was performed of hypoglossal nerve transfer in six patients with obstetric brachial palsy taking into account the factors donor site morbidity and extent of recovery. Hypoglossal nerve transfer was employed in four children for elbow flexion only; in two patients for elbow flexion as well as for elbow extension. The transfer was part of an extended brachial plexus reconstruction for treatment of obstetric brachial plexus palsy. After a mean post-operative interval of 52 months (SD+/-8.1), two professional speech therapists investigated late donor site morbidity by analyzing elementary and communicative functions. The functional result for the arm was assessed using the Mallet scale and by performing a physical examination. Following hypoglossal nerve transfer, early donor site morbidity was significant causing great anxiety in the parents. Late donor site morbidity consisted of serious oral problems in a number of the children. They also showed clear associated movements in the arm during mouth/tongue activity. Recovery of powerful volitional elbow flexion was achieved in four cases only. We do not believe that the sacrifice of such an important function as exerted by the hypoglossal nerve is balanced by the gain demonstrated in our series.

Improved Technique for Harvesting the Accessory Nerve for Transfer in Brachial Plexus Injuries

Objective:

The accessory nerve is frequently used as a donor for nerve transfer in brachial plexus injuries. In currently available techniques, nerve identification and dissection is difficult because fat tissue, lymphatic vessels, and blood vessels surround the nerve. We propose a technique for location and dissection of the accessory nerve between the deep cervical fascia and the trapezius muscle.

Methods:

Twenty-eight patients with brachial plexus palsy had the accessory nerve surgically transplanted to the suprascapular nerve. To harvest the accessory nerve, the anterior border of the trapezius muscle was located 2 to 3 cm above the clavicle. The fascia over the trapezius muscle was incised and detached from the anterior surface of the muscle, initially, close to the clavicle, then proximally. The trapezius muscle was detached from the clavicle for 3 to 4 cm. The accessory nerve and its branches entering the trapezius muscle were identified. The accessory nerve was sectioned as distally as possible. To allow for accessory nerve mobilization, one or two proximal branches to the trapezius muscle were cut. The most proximal branch was always identified and preserved. A tunnel was created in the detached fascia, and the accessory nerve was passed through this tunnel to the brachial plexus.

Results:

In all of the cases, the accessory nerve was easily identified under direct vision, without the use of electric stimulation. Direct coaptation of the accessory nerve with the suprascapular nerve was possible in all patients.

Conclusion:

The technique proposed here for harvesting the accessory nerve for transfer made its identification and dissection easier.

Shoulder function following partial spinal accessory nerve transfer for brachial plexus birth injury

Over a 5-year-period, 26 infants underwent a partial transfer of the spinal accessory nerve into the suprascapular nerve using a nerve graft, as part of the repair of a brachial plexus birth injury. At a minimum follow-up of 2.5 years, all children had shoulder function of Grade 4 or better using a modified Gilbert Scale. Average lateral rotation was measured at 53 degrees.

Sensory reinnervation of a musculocutaneous flap: an experimental rabbit study

Sensory neurotisation of a muscle (sensory nerve transfer to the motor nerve of a muscle) produces muscle sensibility, but not skin sensibility. How to achieve sensation of a musculocutaneous flap remains a challenge to reconstructive microsurgeons. The purpose of our study was to determine if multiple nerve grafts which were placed vertically between the neuromuscular entrance zone of a muscle and a target area of dermis on the overlying skin could improve sensation. Thirty-six gracilis musculocutaneous flaps (18 rabbits) were raised and divided into three groups: group 1 consisted of 12 sensory neurotised gracilis musculocutaneous flaps with five nerve grafts each; group 2 consisted of another 12 sensory neurotised gracilis flaps with 10 nerve grafts each; and the control group consisted of 12 sensory neurotised gracilis musculocutaneous flaps without any nerve grafts. All nerve grafts spanned the distance between the neuromuscular entrance zone of the gracilis muscle and a specified 3 cm diameter area of the skin island. The saphenous nerve (sensory) was coapted to the obturator nerve (motor nerve of the gracilis) in an effort to achieve improved sensation of the skin island in the musculocutaneous flaps. After 6 months, the flaps were individually evaluated using cortical somatosensory evoked potentials (CSSEP) using normal, painful, cold and hot stimuli. One unoperated rabbit was studied as the baseline CSEEP for comparison. Retrograde horseradish peroxidase (HRP) labelling was then performed to evaluate the possibility of newly established neural pathways. Results of the CSSEP testing revealed that flaps possessing 10 nerve grafts (group 2) demonstrated better sensation when compared to flaps possessing five nerve grafts (group 1) or no nerve grafts (control group). Furthermore, retrograde HRP labelling proved that a new neural pathway had been established from the skin island to the dorsal root ganglia of S1 and S2 via the interposed nerve grafts and the sensory neurotised gracilis muscle in groups 1 and 2 rabbits. The control group did not display any sensory regeneration.

Preliminary Results of Double Nerve Transfer to Restore Elbow Flexion in Upper Type Brachial Plexus Palsies

BACKGROUND

Restoration of elbow flexion is the main objective in the treatment of brachial plexus palsies affecting the upper roots. Transfer of the ulnar nerve to the nerve of the biceps has given satisfactory results, but the restored biceps is often weak in cases with avulsions of the C5-C6-C7 roots, in elderly patients, and after long preoperative delays. The authors decided to investigate a double nerve transfer: one or more fascicles of the ulnar nerve to the nerve to the biceps and a fascicle of the median nerve to the motor branch to the brachialis muscle.

METHODS

The authors operated on 15 patients using this technique. The authors have follow-up of more than 6 months in 10 of them. Six had C5-C6 injuries, three had C5-C6-C7 palsies, and one had sustained an infraclavicular injury. The average age was 27.2 years. The average delay before surgery was 6.6 months. The average follow-up was 12.1 months.

RESULTS

Grade 4 elbow flexion was restored in each of the 10 patients. In 10 cases, the patients were able to lift 1 to 5 kg. There was no secondary deficit in grip strength or sensation.

CONCLUSIONS

The results of this technique compare favorably with those of other methods. The percentage of success and the strength of elbow flexion restored were increased without any morbidity. This technique will probably reduce the need for secondary procedures to augment elbow flexion. The authors propose double nerve transfer as a standard procedure in C5-C6 and C5-C6-C7 injuries.

Neuromuscular and neuromusculocutaneous flaps in the rat

Since the introduction of flaps based on the vascular structures of the cutaneous nerves, these have gained increasing popularity in reconstructive surgery. The purpose of this study is to describe a new concept in which the flap is supplied solely by the intrinsic vasculature of a motor nerve. A total of 94 Wistar rats weighing 200-250 g were used in this experiment, which was divided into three sections. In section I, the neural anatomy of the posterior thigh region was investigated. In section II, the flap study using experimental and control groups, was performed. In the experimental group neuromuscular and neuromusculocutaneous flaps were created. The biceps femoris muscle was harvested based solely on its motor nerve as a neuromuscular flap, and together with its overlying skin it was similarly raised as a neuromusculocutaneous flap. In the control group, conventional muscle and musculocutaneous flaps were harvested based on the caudal femoral-popliteal artery vascular axis, and a graft subgroup was created ligating both the constant vascular structure and the motor nerve. In section III, with the intention of augmenting the survival areas of neuromuscular and neuroumusculocutaneous flaps, a surgical delay procedure was applied. On postoperative day 7, the viability of all flaps was evaluated using direct observation, microangiography, and tetrazolium blue stain techniques. The results of the anatomic studies demonstrated a consistent motor nerve arising from the sciatic nerve to the biceps femoris muscle with evident perineural vasculature. Average muscle viability levels of neuromuscular, neuromusculocutaneous, delayed neuromuscular, delayed neuromusculocutaneous, conventional muscle and musculocutaneous flaps were 20.6 +/-7.58, 22.4 +/- 4.21, 86.4 +/- 6.14, 85 +/- 4.21, 89.6 +/- 4.48, and 88.0 +/- 5.51%, respectively. Survival levels of the skin paddles of the neuromusculocutaneous, delayed neuromusculocutaneous, and conventional musculocutaneous flaps were calculated as 13 +/- 17.51, 67 +/- 30.29, and 97+/-4.21%, respectively. In the graft subgroup the viability of muscle and skin paddle was almost nil. In conclusion, our new flap model in a favored laboratory animal is of benefit to researchers in providing a means for future various types of investigations into this new concept. The technique might be considered in further experimental research studies and appropriate clinical situations.

Combined nerve transfers for C5 and C6 brachial plexus avulsion injury

PURPOSE

To report the results of combined nerve transfer in C5 and C6 brachial plexus avulsion injury.

METHODS

Fifteen patients had nerve transfers: spinal accessory nerve to the suprascapular nerve, a part of the ulnar nerve to the biceps motor branch, and the nerve to the long head of the triceps to the anterior branch of the axillary nerve. Patients were evaluated with regard to elbow flexion, shoulder abduction, and shoulder external rotation.

RESULTS

All patients had recovered full elbow flexion: 13 scored M4 and 2 scored M3. Thirteen of the 15 patients obtained good results. The weight the patients could lift ranged from 0 to 7 kg. All patients had recovery of the deltoid function: 13 scored M4 and 2 scored M3. All 15 patients achieved useful functional recovery. Ten patients experienced excellent recoveries and 5 were classified as having good results. The mean shoulder abduction was 115 degrees . Shoulder external rotation strength was scored as M4 in 9 patients, M3 in 4 patients, and M2 in 2 patients. The range of motion of external rotation that was measured from full internal rotation averaged 97 degrees . No clinical donor nerve deficits were observed.

CONCLUSIONS

We recommend combined nerve transfers for C5 and C6 avulsion root injuries. These nerve transfers have the advantage of a quick recovery time as a result of the short regeneration distance without nerve graft.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Radial Sensory Neurotization of the Thumb and Index Finger for Prehension After Proximal Median and Ulnar Nerve Injuries

Proximal median nerve injuries are functionally disabling, secondary to both motor and sensory deficits. Reestablishment of sensation relies on slow axonal regeneration originating from the site of injury after either primary nerve repair or the use of autogenous nerve grafts. This regeneration can take 2 or more years to restore sensation to the hand, depending on injury location. Distal sensory nerve transfers shorten the recovery time by decreasing the required regeneration distance. The authors present two case reports of patients with proximal median nerve injury, who underwent radial sensory nerve transfers to the ulnar digital nerve of the thumb and the radial digital nerve of the index finger. Protective sensation returned to the index and thumb fingertips at 3 months. By 6 months, both patients attained sufficient sensation to permit active lateral key pinch. At 9 months, each patient had moving sensation; and by 14 months, each patient attained proper localization. Successful digital nerve transfers of the dorsal radial sensory nerves in patients with high proximal median nerve injuries return sensation faster than traditional median nerve repairs. Use of this technique will significantly reduce the insensate time in patients with this unfortunate injury.

Bridging the neural gap

A major limitation to overall success in peripheral nerve surgery is time for regeneration. Although one can help speed up the regenerative process to some extent, success is hindered by issues such as number of coaptation sites, supply of donor nerves, and the limitations of nerve substitutes. In the case of a large gap, a nerve graft is often used to fill in the deficit. Autogenous nerve grafts are in limited supply, with sural nerve grafts being the primary source. Alternatives to the standard treatment include vein grafts, synthetic nerve conduits, nerve transfers, and nerve transplantation. Schwann cell-lined nerve conduits and tissue-engineered substitutions are still in their infancy and have some limited clinical application.

Early effect of gene therapy on a direct muscle neurotization model

Direct nerve-to-muscle neurotization has been the subject of both clinical and experimental studies. In this study, the authors report a new animal model to test the regenerative properties of a nerve (musculocutaneous) implanted in a muscle (biceps). They also report the early effects of the application at the implantation site of exogenously administered Brain Derived Nerve Factor (BDNF) and of endogenously produced BDNF, via the administration of an adenoviral construct with a tissue-specific promotor for muscle cells (AdRSV), and containing the BDNF gene. Evaluation included behavioral testing (grooming test), electrical stimulation, Western blot analysis of the distal implanted nerve to determine the presence of locally produced BDNF, and motor end-plate staining of the biceps muscle. At the early time point of 1 week following the musculocutaneous nerve to biceps muscle implantation, there was no increased production of recombinant BDNF at the distal implanted musculocutaneous nerve, as assessed by Western blot analysis. Therefore, there was no significant difference in the behavioral evaluation of the animals at 1 week; the Terzis grooming test showed no statistical difference among groups, but a trend toward better function for the BDNF and the high-dose AdRSV-BDNF groups, compared to the control groups. There was also no difference in the histologic appearance and number of the motor end-plates at the implantation site, compared to the controls. The electrical stimulation of the MC nerve did not produce statistically significant results among the experimental groups. In this direct nerve to muscle neurotization model, the application of AdRSV-BDNF at 3 x 10 (9) pfu/ul did not show enhanced production of BDNF at 1 week.

[Clinical comparison of vascularized and non-vascularized full-length phrenic nerve]

OBJECTIVE

To investigate the clinical effect of vascularized and non-vascularized full-length phrenic nerve transfer on treating brachial plexus injury.

METHODS

From August 1999 to March 2000, full-length phrenic nerve transfer to musculocutaneous nerve was conducted with the technique of Video-Assisted-Thoracic-Surgery in 15 patients (M 13, F 2) that all suffered from avulsion. Three kinds of procedures were carried out. The first was retaining initial point of phrenic nerve and dissecting full-length distal nerve (group A). The second was keeping cervical segment and isolating thoracic segment of phrenic nerve (group B). The last was vascularized phrenic nerve transfer (group C). All these phrenic nerves were sutured to musculocutaneous nerves. The results of electrophysiology and function of biceps brachii muscle were compared.

RESULTS

The length of the dissecting full-length distal nerves in group A, group B and group C compared with that of conventional operation increased by 17.8 +/- 1.1 cm, 10.2 +/- 1.0 cm and 8.8 +/- 0.5 cm respectively. There was significant difference when group A was compared with group B and group C, when group B was compared with group C. All three procedures had no significant difference and led to the same function recovery of biceps brachii muscle to grade II about 6 months later.

CONCLUSION

There is no difference in treating effect between vascularized and non-vascularized full-length phrenic nerve transfer, when the recipient bed has normal vascularity.

[Recent development of extraplexal neurotization as a treatment for brachial plexus injuries]

OBJECTIVE

To review the recent development of extraplexal neurotization as a treatment for brachial plexus injuries.

METHODS

Relevant literature was extensively reviewed. The new development, the advantages and disadvantages of extraplexal neurotization were comprehensively evaluated and analyzed.

RESULTS

After many years of clinical research, great improvement in treatment of brachial plexus injuries was achieved. There were more donor nerves and better use of every donor nerve was made.

CONCLUSION

Extraplexal neurotization is an effective treatment for brachial plexus injuries.

[Transpositional anastomosis of C7 posterior root and spinal accessory nerve to reconstruct the trapezius muscle function]

OBJECTIVE

To introduce a new approach of neurotization to treatment of the shoulder syndrome after the radical neck dissection by using transpositional anastomosis of C7 posterior root and the spinal accessory nerve to reconstruct the function of trapezius muscle.

METHODS

From March 1999 to February 2001, 10 patients underwent the neurotization during the radical neck dissection. In the operation, the apo-cranial part of spinal accessory nerve was preserved from the trapezius muscle (> 3. 0 cm in length) and anastomosed to C7 posterior root. Objective physical examinations and electromyography were conducted before and after operation. One, 6 and 12 months after operation the trapezius muscle function after the transpositional anastomosis was evaluated.

RESULTS

One, 6 and 12 months after operation, the recovery rates of each part were as follows: 9.8%, 68.9% and 73.5% in upper part; 4.7%, 73.6% and 69.4% in middle part; and 6.2%, 70.5% and 70.3% in lower part. The range of abduction motion of upper arm in 7 cases (70%) exceeded 90 degrees. The mean maximal abduction angle was more than 95 degrees. Evaluation of the shoulder function showed that myoatrophy was mild and the disability of abduction was classified as grade II in 7 cases and grade II in 3 cases.

CONCLUSION

Transpositional anastomosis of the C7 posterior root to the spinal accessory nerve after radical neck dissection can well reconstruct the function of trapezius muscle. This approach provides a wide indication in comparison with the functional neck dissection without impairment of arm function after the cutting of C7.

End-to-Side Nerve Grafts: Experimental Study in Rats

The effectiveness of the end-to-side nerve graft in comparison with the end-to-end cable-graft was determined in rat sciatic nerve transection models. Sixty Sprague-Dawley rats were randomly divided into four groups with different reconstructive methods for two branches of the sciatic nerve: Group I, median nerve graft with end-to-side neurorrhaphy; Group II, median and ulnar nerve grafts with end-to-end neurorrhaphy; Group III, no repair; and Group IV, sham operation. Between Groups I and II, there were no significant differences in the functional, electrophysiologic, and histologic evaluations. In retrograde tracing of the spinal cord and dorsal root ganglia, the number of double-labeled neurons was significantly higher in Group I. End-to-side nerve grafts show good functional recovery, require less graft, and are easy to perform. The authors find this method to be an effective alternative in facial nerve reconstruction and of great value in various kinds of peripheral nerve surgery.

Nerve reconstruction in lumbosacral plexopathy. Case report and review of the literature

Neurological injury to the lumbosacral plexus associated with pelvic and sacral fractures has traditionally been treated conservatively, despite significant and often debilitating functional deficits of the lower extremities. The authors report a case of reconstruction of the lumbosacral plexus, including nerve grafting to restore lower-extremity function caused by severe trauma to the pelvis. A 16-year-old boy sustained pelvic and sacral fractures in a motor vehicle accident. After stabilization of his orthopedic injuries, he suffered from paresis of his right gluteal and hamstring muscles and had no motor or sensory function below his knee. Two months later, he underwent reconstruction of his lumbosacral plexus performed using a nerve graft from his L-5 and S-1 nerve roots proximal to the inferior gluteal nerve and distal to a branch to the hamstring muscles. After another 2 months, his recovering saphenous nerve was transferred to the sensory component of the posterior tibial nerve by using cabled sural nerve grafts to restore sensation to the sole of his foot. After 2.5 years, he experienced reinnervation of his gluteal and hamstring muscles and could perceive vibration on the sole of his foot. With the assistance of a foot-drop splint, the patient ambulates well and is able to ski. Operative details and the relevant literature are reviewed.