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Schäfer B, Beier JP, Bahm J. [Nerve Transfers in Children with Non-traumatic Amyoplasia]. HANDCHIR MIKROCHIR P 2024; 56:55-64. [PMID: 38508206 DOI: 10.1055/a-2240-4781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND The treatment of obstetric brachial plexus palsy through primary reconstruction and nerve transfers has been established in the past decades. In the case of non-traumatic diseases that lead to flaccid paralysis and the inability to move the extremities, such as transverse myelitis (TM) or arthrogryposis multiplex congenita (AMC), which can have a wide variety of causes, the focus has been on rehabilitative therapy so far, while surgical interventions have been used to a lesser extent, e. g., in the form of osteotomies or muscle transfers. Our aim is to establish nerve transfers as a surgical option to improve mobility in non-traumatic amyoplasia. PATIENTS This work presents the needs-adapted treatment of a total of 23 patients (aged 4 months to 64 months, 18 with AMC and 5 with TM) using nerve transfers on the upper extremity. RESULTS We were able to show that early nerve transfers in the upper extremity enabled the reanimation of muscles in both AMC and TM. CONCLUSION This work shows that the treatment of non-traumatic amyoplasia in children with selective nerve grafts is a successful method. Nerve transfers allow patients to gain or regain important functions for managing independent everyday life. The surgical methods have been established in the treatment of traumatic nerve injuries. They are well-known and can be carried out safely. We believe that this is an important treatment option for paediatric patients with paralysis associated with TM or AMC, which should also be known to the treating physicians.
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Affiliation(s)
- Benedikt Schäfer
- Department of Plastic Surgery, Hand Surgery - Burn Center, Division for Plexus Surgery, University Hospital RWTH Aachen, Germany
- Department of Plastic Surgery, Hand Surgery - Burn Center, Division for Plexus Surgery, University Hospital RWTH Aachen, Germany
| | - Justus P Beier
- Department of Plastic Surgery, Hand Surgery - Burn Center, Division for Plexus Surgery, University Hospital RWTH Aachen, Germany
| | - Jörg Bahm
- Department of Plastic Surgery, Hand Surgery - Burn Center, Division for Plexus Surgery, University Hospital RWTH Aachen, Germany
- Department of Plastic Surgery, Hand Surgery - Burn Center, Division for Plexus Surgery, University Hospital RWTH Aachen, Germany
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Fiani B, Covarrubias C, Jarrah R. Neuroimmunology and Novel Methods of Treatment for Acute Transverse Myelitis. Cureus 2021; 13:e17043. [PMID: 34522521 PMCID: PMC8428159 DOI: 10.7759/cureus.17043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/09/2021] [Indexed: 11/05/2022] Open
Abstract
Acute transverse myelitis (ATM) is a rare, immune-mediated pathology that is defined as an adverse inflammatory response in the spinal cord leading to neurologic injury. The pathophysiology of ATM is poorly understood, with no apparent differences in age, ethnicities, or race, along with variable radiographic and clinical presentation. Therefore, in this review, we will characterize what is known about ATM's etiology and diagnostic criteria, and relate it to properties of neuroimmunology. Moreover, we will further discuss current treatment options, along with potential novel methods, to provide a comprehensive overview of the status of ATM's research development. Among these novel treatments, potassium blockers reveal exciting early outcomes in restoring neurologic motor function. In addition, human glial progenitor cell transportations have been described as a potential treatment through integrating and remyelinating lesion sites. Nevertheless, despite these novel methods, there is a paucity of clinical trials establishing ATM's immunopathology and the therapeutic role of potential treatment methods. Therefore, we will highlight the importance of larger well-designed clinical trials in revealing significant biomarkers of injury and recovery.
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Affiliation(s)
- Brian Fiani
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
| | - Claudia Covarrubias
- School of Medicine, Universidad Anáhuac Querétaro, Santiago de Querétaro, MEX
| | - Ryan Jarrah
- College of Arts and Sciences, University of Michigan - Flint, Flint, USA
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Lubelski D, Pennington Z, Tuffaha S, Moore A, Belzberg AJ. Sciatic-to-Femoral Nerve End-to-End Coaptation for Proximal Lower Extremity Function in Patients With Acute Flaccid Myelitis: Technical Note and Review of the Literature. Oper Neurosurg (Hagerstown) 2021; 21:20-26. [PMID: 33733670 DOI: 10.1093/ons/opab057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/25/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is an acute-onset anterior horn disease resulting in flaccid paralysis of extremities, trunk, facial, and cervical musculature in children following upper respiratory or gastrointestinal viral illness. Nerve transfer procedures have been shown to restore function. OBJECTIVE To present a technical description of sciatic-to-femoral nerve transfers in 4 children with AFM. METHODS Retrospective review of relevant cases was performed. RESULTS A total of 4 cases are presented of young children with persistent quadriparesis in the setting of AFM, presenting between 4 and 15 mo following initial diagnosis. Electromyography showed denervation of muscles innervated by the femoral nerve, with sparing of the sciatic distribution. The obturator nerve was also denervated in all patients. We therefore elected to pursue sciatic-to-femoral transfers to restore active knee extension. These transfers involved end-to-end coaptation of a sciatic nerve fascicle to the femoral nerve motor branches supplying quadriceps muscles. CONCLUSION We present technical descriptions of bilateral sciatic-to-femoral nerve neurotization for the restoration of quadriceps function in 4 patients with AFM. The sciatic nerve fascicles are a reasonable alternative donor nerve for patients with proximal muscle paralysis and limited donor options in the lower extremity.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sami Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
BACKGROUND Acute flaccid myelitis (AFM) syndrome consists of loss of lower motor neurons following a viral infection, with preserved sensory function. It usually affects the upper limbs asymmetrically, with proximal more than distal muscle involvement. METHODS Five cases were surgically treated with nerve transfers: spinal accessory to suprascapular nerve transfer (4 patients), branch of radial nerve to axillary nerve transfer (Somsak's procedure) (2 patients), and transfer of a fascicle of the ulnar nerve to the motor branch to the biceps (Oberlin's procedure) (1 patient). RESULTS Motor improvement was seen in three cases. Widespread motor involvement was associated with poor outcome. CONCLUSION This small series of cases reinforces that nerve transfers are a reliable option for treatment of selected children with AFM.
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Paziuk TM, Tadley M, Aversano M, Kozin SH, Zlotolow DA. The Utilization of Nerve Transfer for Reestablishing Shoulder Function in the Setting of Acute Flaccid Myelitis: A Single-Institution Review. Pediatr Neurol 2020; 111:17-22. [PMID: 32951650 DOI: 10.1016/j.pediatrneurol.2020.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a rare disease of young children. The typical presentation involves acute-onset flaccid paralysis in one or more extremities with a nonspecific viral prodrome. Long-term outcomes demonstrate that functional recovery plateaus around six to nine months. The purpose of this study was to evaluate the efficacy of nerve transfers for restoring shoulder function in these patients. METHODS A retrospective review of all patients diagnosed with AFM at a single institution. Shoulder function was evaluated using the active movement scale (AMS). Children at a minimum of six months after diagnosis with plateaued shoulder AMS scores of 4 or less were indicated for surgery. RESULTS Eleven patients were identified with a mean time from symptom onset to surgery of 12 months. Average follow-up was 19 months. The mean AMS score at follow-up for shoulder external rotation and abduction was 4.6 and 2.8, respectively. A total of six different nerve transfers with five different donor nerves were used individually or in conjunction with each other. The most common transfers were from the spinal accessory nerve to the suprascapular nerve (n = 8) and from the intercostal nerves ×3 to the axillary nerve (n = 5). Patients who received a transfer from the radial nerve to the axillary nerve (n = 2) had the best functional returns, with the mean AMS score of 6.5 in both external rotation and abduction at follow-up. CONCLUSION Nerve transfer procedures may help restore shoulder function in the setting of AFM. Combination procedures that involve a transfer from the radial nerve to the axillary nerve may provide the best functional results.
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Affiliation(s)
| | | | | | - Scott H Kozin
- Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Dan A Zlotolow
- Shriners Hospital for Children, Philadelphia, Pennsylvania
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Pino PA, Intravia J, Kozin SH, Zlotolow DA. Early results of nerve transfers for restoring function in severe cases of acute flaccid myelitis. Ann Neurol 2019; 86:607-615. [DOI: 10.1002/ana.25558] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/14/2019] [Accepted: 07/21/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Paula A. Pino
- Department of Orthopedic SurgeryPontifical Catholic University of Chile Santiago Chile
| | | | - Scott H. Kozin
- Department of Orthopedic SurgeryShriners Hospital for Children–Philadelphia Philadelphia PA
| | - Dan A. Zlotolow
- Department of Orthopedic SurgeryShriners Hospital for Children–Philadelphia Philadelphia PA
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Hagemann C, Stücker R, Breyer S, Kunkel POS. Nerve transfer from the median to musculocutaneous nerve to induce active elbow flexion in selected cases of arthrogryposis multiplex congenita. Microsurgery 2019; 39:710-714. [PMID: 30891796 DOI: 10.1002/micr.30451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/20/2019] [Accepted: 03/08/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Arthrogryposis multiplex congenita (AMC) is a rare disease which affects mainly upper and lower extremities. Affected patients are not able to eat unassisted due to elbow contracture and nonexistent active elbow flexion. In traumatic brachial plexus palsies, a nerve transfer from either median or ulnar nerve to the musculocutaneous nerve has proved to induce active elbow flexion, and we report our results of such a procedure in a nontraumatic condition, that is, arthrogryposis. METHODS We selected four patients with AMC type 1 (6 extremities, 2 males, 2 females) diagnosed with AMC presenting to our institution shortly after birth from 2014 to 2016 to perform a nerve transfer from the median nerve to the musculocutaneous nerve in order to induce active elbow flexion. The indication of application of this surgical procedure was based on active finger and wrist flexion, limited contracture of elbow joints and evidence of flexing muscle fibers detected by sonography. RESULTS Five nerve transfers were conducted with a follow up of 2-5 years. Two extremities reached active elbow flexion motorgrade M4, two M3, and one M1 at latest follow up. One patient developed a postoperative suture granuloma. One nerve transfer was abandoned due to neuroanatomic variation. One extremity was treated with botulinum toxin in triceps muscle in addition to the nerve transfer. CONCLUSIONS In this series of selected cases of AMC Type 1 we were able to induce active elbow flexion using a nerve transfer technique developed for traumatic and obstetric brachial plexus palsies. In four extremities the procedure achieved independent hand-to-mouth active elbow flexion. Level of evidence four.
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Affiliation(s)
- Christian Hagemann
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Hamburg, Germany
| | - Ralf Stücker
- Department of Pediatric Orthopedic Surgery, Altona Children's Hospital, Hamburg, Germany.,Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Breyer
- Department of Pediatric Orthopedic Surgery, Altona Children's Hospital, Hamburg, Germany.,Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philip O S Kunkel
- Department of Pediatric Neurosurgery, Altona Children's Hospital, Hamburg, Germany
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Saltzman EB, Rancy SK, Sneag DB, Feinberg Md JH, Lange DJ, Wolfe SW. Nerve Transfers for Enterovirus D68-Associated Acute Flaccid Myelitis: A Case Series. Pediatr Neurol 2018; 88:25-30. [PMID: 30301588 DOI: 10.1016/j.pediatrneurol.2018.07.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 07/21/2018] [Accepted: 07/31/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Acute flaccid myelitis is associated with enterovirus D68 -induced inflammation and destruction of cervical anterior horn cells. To date, no medical intervention has altered the disease course. METHODS We report two pediatric patients who were treated with nerve transfer in three limbs with sustained upper extremity neuropathy. Postoperative outcomes included muscle strength, graded on the British Medical Research Council (BMRC) scale, range of motion, and electromyography. RESULTS Two years postoperatively, Patient 1 had improved elbow flexion to BMRC grade 4+, 125° of flexion, and discrete to decreased motor unit recruitment in targeted muscles. Twenty-one months postoperatively, Patient 2 demonstrated right brachialis flexion to BMRC grade 4+/5 and deltoid firing with simultaneous pectoralis major recruitment, and limited but active flexor digitorum profundus flexion. CONCLUSIONS Both patients continue to demonstrate functional recovery two years postoperatively. These outcomes suggest a promising reconstructive technique for this emerging and devastating viral endemic.
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Affiliation(s)
- Eliana B Saltzman
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, New York
| | - Schneider K Rancy
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, New York
| | - Darryl B Sneag
- Department of Radiology, Hospital for Special Surgery, New York, New York
| | - Joseph H Feinberg Md
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, New York
| | - Dale J Lange
- Department of Neurology, Hospital for Special Surgery, New York, New York; Weill Medical College of Cornell University, New York, New York; New York-Presbyterian Hospital, New York, New York
| | - Scott W Wolfe
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery, New York, New York; Weill Medical College of Cornell University, New York, New York; New York-Presbyterian Hospital, New York, New York.
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Siqueira MG, Socolovsky M, Heise CO, Martins RS, Di Masi G. Efficacy and Safety of Oberlin's Procedure in the Treatment of Brachial Plexus Birth Palsy. Neurosurgery 2012; 71:1156-60; discussion 1161. [PMID: 23037815 DOI: 10.1227/neu.0b013e318271ee4a] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
BACKGROUND:
In brachial plexus injuries, when there are no available roots to use as a source for graft reconstruction, nerve transfers emerge as an elective technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. Despite the high rate of good to excellent results in adults, this technique is seldom used in children.
OBJECTIVE:
To evaluate the efficacy and safety of Oberlin's procedure in the surgical treatment of brachial plexus birth palsy.
METHODS:
Striving to restore elbow flexion, we performed Oberlin's procedure in 17 infants with brachial plexus birth palsy. After follow-up of at least 19 months, primary outcomes were the strength of elbow flexion (modified British Medical Research Council Scale), hand function measured using Al-Qattan's Scale, and comparative x-rays of both hands to detect altered growth.
RESULTS:
Good to excellent results related to biceps contraction were obtained in 14 patients (82.3%) (3/MRC3, 11/MRC4). The preoperative Al-Qattan Scale score for the hand was maintained at final follow-up. Comparing the treated and normal limb, no difference was observed in hand development by x-ray.
CONCLUSION:
Oberlin's procedure is an effective and safe option for the surgical treatment of upper brachial plexus birth palsy.
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Affiliation(s)
- Mario G. Siqueira
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Mariano Socolovsky
- Peripheral Nerve and Plexus Surgery Program, Division of Neurosurgery, University of Buenos Aires, Buenos Aires, Argentina
| | - Carlos Otto Heise
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Roberto S. Martins
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Gilda Di Masi
- Peripheral Nerve and Plexus Surgery Program, Division of Neurosurgery, University of Buenos Aires, Buenos Aires, Argentina
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