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Socolovsky M, di Masi G, Bonilla G, Lovaglio A, Battaglia D, Rosler R, Malessy M. Brain plasticity in neonatal brachial plexus palsies: quantification and comparison with adults' brachial plexus injuries. Childs Nerv Syst 2024; 40:479-486. [PMID: 37436472 DOI: 10.1007/s00381-023-06072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE To compare two populations of brachial plexus palsies, one neonatal (NBPP) and the other traumatic (NNBPP) who underwent different nerve transfers, using the plasticity grading scale (PGS) for detecting differences in brain plasticity between both groups. METHODS To be included, all patients had to have undergone a nerve transfer as the unique procedure to recover one lost function. The primary outcome was the PGS score. We also assessed patient compliance to rehabilitation using the rehabilitation quality scale (RQS). Statistical analysis of all variables was performed. A p ≤ 0.050 set as criterion for statistical significance. RESULTS A total of 153 NNBPP patients and 35 NBPP babies (with 38 nerve transfers) met the inclusion criteria. The mean age at surgery of the NBPP group was 9 months (SD 5.42, range 4 to 23 months). The mean age of NNBPP patients was 22 years (SD 12 years, range 3 to 69). They were operated around sixth months after the trauma. All transfers performed in NBPP patients had a maximum PGS score of 4. This was not the case for the NNBPP population that reached a PGS score of 4 in approximately 20% of the cases. This difference was statistically significant (p < 0.001). The RQS was not significantly different between groups. CONCLUSION We found that babies with NBPP have a significantly greater capacity for plastic rewiring than adults with NNBPP. The brain in the very young patient can process the changes induced by the peripheral nerve transfer better than in adults.
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Affiliation(s)
- Mariano Socolovsky
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina.
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina.
| | - Gilda di Masi
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina
| | - Gonzalo Bonilla
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina
| | - Ana Lovaglio
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Torre 2 5A, 1428, Buenos Aires, Argentina
- Peripheral Nerve & Brachial Plexus Surgery Unit, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Torre 2 5A, Buenos Aires, Argentina
| | - Danilo Battaglia
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Physiotherapy and Rehabilitation, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Roberto Rosler
- Department of Neurology, Universidad Abierta Interamericana, Buenos Aires, Argentina
| | - Martijn Malessy
- Department of Neurosurgery, University of Leiden School of Medicine, Leiden, Holland
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Socolovsky M, Lu JCY, Zarra F, Wei CK, Chang TNJ, Chuang DCC. Effects of COVID-19 Pandemic in Patients with a Previous Phrenic Nerve Transfer for a Traumatic Brachial Plexus Palsy. J Brachial Plex Peripher Nerve Inj 2024; 19:e20-e26. [PMID: 38868462 PMCID: PMC11168810 DOI: 10.1055/s-0044-1787296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/03/2024] [Indexed: 06/14/2024] Open
Abstract
Background With the advent of the coronavirus disease 2019 (COVID-19) pandemic, some doubts have been raised regarding the potential respiratory problems that patients who previously underwent a phrenic nerve transfer could have. Objectives To analyze the effects of the coronavirus infection on two populations, one from Argentina and another from Taiwan. Specific objectives were: (1) to identify the rate of COVID in patients with a history of phrenic nerve transfer for treatment of palsy; (2) to identify the overall symptom profile; (3) to compare Argentinian versus Taiwanese populations; and (4) to determine if any phrenic nerve transfer patients are at particular risk of more severe COVID. Methods A telephonic survey that included data regarding the number of episodes of acute COVID-19 infection, the symptoms it caused, the presence or absence of potential or life-threatening complications, and the status of COVID-19 vaccination were studied. Intergroup comparisons were conducted using the nonparametric Mann-Whitney U test, with categorical variables conducted using either the Pearson χ2 analysis or the Fisher's exact test, as appropriate. Results A total of 77 patients completed the survey, 40 from Taiwan and 37 from Argentina. Fifty-five (71.4%) developed a diagnosis of COVID. However, among these, only four had any level of dyspnea reported (4/55 = 7.3%), all mild. There were also no admissions to hospital or an intensive care unit, no intubations, and no deaths. All 55 patients isolated themselves at home. Conclusions It can be concluded that an acute COVID-19 infection was very well tolerated in our patients. (Level of evidence 3b, case reports).
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Affiliation(s)
- Mariano Socolovsky
- Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Francisco Zarra
- Department of Neurosurgery, Sanatorio Guemes, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Chen Kuan Wei
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Kakinoki R, Ohtani K, Ohta S, Ikeguchi R, Akagi M, Goto K. Treatment of Complete Brachial Plexus Injuries Using Double Free Muscle Transfer. J Hand Surg Am 2023:S0363-5023(23)00497-5. [PMID: 37921713 DOI: 10.1016/j.jhsa.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE The purpose of this study was to examine the surgical outcomes of double free muscle transfer (DFMT) performed in patients with complete brachial plexus injury (BPI). METHODS We retrospectively analyzed the outcomes of DFMT for 12 patients with complete BPI who were followed up for more than 2 years after the final muscle transplantation. Their mean age was 29 years (range, 18-41). Three patients underwent contralateral C7 nerve root transfer before the DFMT. The range of motion (ROM) of the shoulder, elbow, and fingers was measured. Patient-reported outcome measures, including Disability of the Shoulder, Arm, and Hand (DASH) scores and visual analog scale (VAS) scores for pain, were also examined. RESULTS The mean shoulder ROM against gravity was 22° ± 8° in abduction and 33° ± 5° in flexion. Seven patients underwent phrenic nerve (PhN) transfer to the suprascapular nerves, and five exhibited asymptomatic lung impairment on spirography more than 2 years after PhN transfer. The mean elbow ROM against gravity was 111° ± 9° in flexion and -32° ± 7° in extension. All patients obtained elbow flexion >90° against a 0.5-kg weight. All patients obtained touch sensation and two recognized warm and cold sensations in the affected palm. The mean total active motion of the affected fingers was 44° ± 11°. All patients exhibited hook function of the hands. The mean preoperative and postoperative DASH scores were 70.3 ± 13.4 and 51.8 ± 15.9, respectively. The mean pain VAS score was 28 ± 31 at the final follow-up. CONCLUSIONS Double free muscle transfer provided patients with complete brachial plexus palsy with good elbow flexion and hand hook functions. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ryosuke Kakinoki
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan.
| | - Kazuhiro Ohtani
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
| | - Souichi Ohta
- Department of Orthopedic Surgery, Kansai Electric Power Hospital, Osaka, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masao Akagi
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
| | - Koji Goto
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
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Fochtmann-Frana A, Pretterklieber B, Radtke C, Pretterklieber ML. Phrenic Nerve Transfer to Musculocutaneous Nerve: An Anatomical and Histological Study. Life (Basel) 2023; 13:1892. [PMID: 37763296 PMCID: PMC10532453 DOI: 10.3390/life13091892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/26/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND To restore elbow flexor muscle function in case of traumatic brachial plexus avulsion, the phrenic nerve transfer to the musculocutaneous nerve has become part of clinical practice. The nerve transfer can be done by means of video-assisted thoracic surgery without nerve graft or via supraclavicular approach in combination with an autograft. This study focuses on a detailed microscopic and macroscopic examination of the phrenic nerve. It will allow a better interpretation of existing clinical results and, thus, serve as a basis for future clinical studies. MATERIAL AND METHODS An anatomical study was conducted on 28 body donors of Caucasian origin (female n = 14, male n = 14). A sliding caliper and measuring tape were used to measure the diameter and length of the nerves. Sudan black staining was performed on 15 µm thick cryostat sections mounted on glass slides and the number of axons was determined by the ImageJ counting tool. In 23 individuals, the phrenic nerve could be examined on both sides. In 5 individuals, however, only one side was examined. Thus, a total of 51 nerves were examined. RESULTS The mean length of the left phrenic nerves (33 cm (29-38 cm)) was significantly longer compared to the mean length of the right phrenic nerves (30 cm (24-33 cm)) (p < 0.001). Accessory phrenic nerves were present in 9 of 51 (18%) phrenic nerves. The mean number of phrenic nerves axons at the level of the first intercostal space in body donors with a right accessory phrenic nerve was significantly greater compared to the mean number of phrenic nerves axons at the same level in body donors without a right accessory phrenic nerve (3145 (range, 2688-3877) vs. 2278 (range, 1558-3276)), p = 0.034. A negative correlation was registered between age and the nerve number of axons in left (0.742, p < 0.001) and right (-0.273, p = 0.197) phrenic nerves. The mean distance from the upper edge of the ventral ramus of the fourth cervical spinal nerve to the point of entrance of the musculocutaneous nerve between the two parts of the coracobrachialis muscle was 19 cm (range, 15-24 cm) for the right and 20 cm (range, 15-25 cm) for the left arm. CONCLUSIONS If an accessory phrenic nerve is available, it presumably should be spared. Thus, in that case, a supraclavicular approach in combination with a nerve graft would probably be of advantage.
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Affiliation(s)
- Alexandra Fochtmann-Frana
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Bettina Pretterklieber
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Auenbruggerplatz 25, 8036 Graz, Austria; (B.P.); (M.L.P.)
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Waehringer Str. 13, 1090 Vienna, Austria
| | - Christine Radtke
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Michael L. Pretterklieber
- Division of Macroscopic and Clinical Anatomy, Gottfried Schatz Research Center, Medical University of Graz, Auenbruggerplatz 25, 8036 Graz, Austria; (B.P.); (M.L.P.)
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Waehringer Str. 13, 1090 Vienna, Austria
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Restoration of Grasp after Single-Stage Free Functioning Gracilis Muscle Transfer in Traumatic Adult Pan-Brachial Plexus Injury. Plast Reconstr Surg 2023; 151:133-142. [PMID: 36219863 DOI: 10.1097/prs.0000000000009787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND A variety of approaches have been described to obtain rudimentary grasp after traumatic pan-brachial plexus injury in adults. The aim of this study is to evaluate hand prehension after a gracilis single-stage free functioning muscle transfer. METHODS Twenty-seven patients who underwent gracilis single-stage free functioning muscle transfer for elbow flexion and hand prehension after a pan-plexus injury were included. All patients presented with a minimum of 2 years of follow-up. Postoperative finger flexion, elbow flexion strength, preoperative and postoperative Disability of the Arm, Shoulder, and Hand questionnaire scores, secondary hand procedures, complications, and demographic characteristics were analyzed. RESULTS Twenty patients (74%) demonstrated active finger pull-through. Only six patients (25%) considered their hand function useful for daily activities. Disability of the Arm, Shoulder, and Hand score improved by 13.1 ± 13.7 ( P < 0.005). All patients were expected to require one secondary procedure (wrist fusion, thumb carpometacarpal fusion, and/or thumb interphalangeal fusion) because no extensor reconstruction was performed. These were performed in 89%, 78%, and 74% of patients, respectively. Four postoperative complications (hematoma, seroma, wound dehiscence, and skin paddle loss) occurred. No flap loss occurred. CONCLUSIONS In pan-plexus injuries, the use of a gracilis single-stage free functioning muscle transfer is an alternative to the double free functioning muscle transfer procedure and contralateral C7 transfer, especially for patients who are unable to undergo two to three important operations in a short period of time. Further research and studies are required to improve hand function in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Ferraresi S, Basso E, Maistrello L, Di Pasquale P. The reanimation of the elbow functions in avulsive injuries of the upper brachial plexus using the medial cord transfer: nuances of the technique and update. Neurol Res 2023; 45:1-10. [PMID: 35981101 DOI: 10.1080/01616412.2022.2112645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Report on a new transfer for the reinnervation of biceps and brachialis muscles after multilevel avulsive injuries of brachial plexus provided at least T1 is viable: the Medial Cord to Musculocutaneous (MCMc) and its variant, the Medial Cord to anterior Upper Trunk (MC-aUT). The MC-aUT is indicated in agenesia of musculocutaneous nerve and when a residual function in the biceps is present. The MCMc transfer would be unfeasible in the former and contraindicated in the latter. METHODS Three hundred and five consecutive patients, classified according to the quality of hand function, are available for a long-term follow-up after reconstructive surgery. They had multiple cervical root avulsive injuries at two (C5-C6), three (C5-C6-C7) and four (C5-C6-C7-C8) levels. The reinnervation was obtained via an end-to-end transfer from two donor fascicles located in the medial cord (MC) and aimed at the flexor carpi ulnaris or the flexor digitorum profundus. RESULTS These transfers have no failures and no complications when the hand shows a normal function. In the case of suboptimal conditions of the hand, the technique is more challenging, but still has many satisfactory results. In the four-root avulsive injuries, on the contrary, strong limitations suggest that different strategies should be preferred. EMG shows a reinnervation in both biceps and brachialis muscles and this accounts for the quality of results. Tendon transfers for wrist and finger dorsiflexion, when required, remain unencumbered. DISCUSSION The procedures are safe, effective and easily feasible. The ideal candidate has a C5-C6 injury and a normal hand function.
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Affiliation(s)
- Stefano Ferraresi
- Department of Neurosurgery, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Elisabetta Basso
- Department of Neurosurgery, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Lorenzo Maistrello
- Department of Neurosurgery, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Piero Di Pasquale
- Department of Anesthesiology, Ospedale Santa Maria della Misericordia, Rovigo, Italy
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Crowe CS, Pulos BP, Spinner RJ, Shin AY. Respiratory Failure After Supraclavicular Nerve Block in a Patient With a Contralateral Brachial Plexus Injury: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00004. [PMID: 36206361 DOI: 10.2106/jbjs.cc.22.00331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/31/2022] [Indexed: 11/07/2022]
Abstract
CASE A patient with prior left-sided brachial plexus trauma and associated left phrenic nerve paralysis subsequently developed transient respiratory failure after a contralateral supraclavicular nerve block. Her known left phrenic nerve palsy secondary to her index brachial plexus injury was rediscovered during the workup of her acute respiratory distress, which resulted in an emergent intensive care unit admission. CONCLUSION The paralysis of her right phrenic nerve at the time of left-sided regional anesthesia was identified as the etiology of near-complete bilateral diaphragmatic paralysis and respiratory failure.
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Affiliation(s)
- Christopher S Crowe
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
| | - Bridget P Pulos
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Alexander Y Shin
- Division of Hand and Upper Extremity Surgery, Department of Orthopaedics, Mayo Clinic, Rochester, Minnesota
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Socolovsky M, Barillaro K, Bonilla G, Masi GD, Malessy M. Nerve transfers for brachial plexus injuries: grading of volitional control. J Neurosurg 2022; 138:1419-1425. [PMID: 36115049 DOI: 10.3171/2022.7.jns22887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE After brachial plexus injuries (BPIs), nerve transfers are used to restore lost muscle function. Brain plasticity underlies the process of regaining volitional control, which encompasses disconnection of the original donor nerve-related programs and reconnection to acceptor nerve programs. To the authors' knowledge, the levels of disconnection and reconnection have never been studied systematically. In this study, the authors developed a novel 4-point plasticity grading scale (PGS) and assessed the degree of volitional control achieved, identifying clinical correlations with this score. METHODS Patients with BPI who underwent a phrenic, spinal accessory, median, and/or ulnar fascicle nerve transfer to restore biceps and deltoid function were asked to maximally contract their target muscle as follows: 1) by using only the donor nerve program, and 2) by activating the target muscle while consciously trying to avoid using the donor nerve, with assessment each time of the Medical Research Council (MRC) scale grade for muscle strength. The authors' PGS was used to rate the level of volitional control achieved. PGS grade 1 represented the lowest independent volitional control, with MRC grade 4 obtained in response to the donor command and MRC grade 0 in response to the acceptor command (minimum brain plasticity), whereas PGS grade 4 was no noticeable contraction in response to the donor command and MRC grade 4 in response to the acceptor command (maximum brain plasticity). RESULTS In total, 153 patients were studied. For biceps restoration, the phrenic nerve was used as a donor in 44 patients, the spinal accessory nerve in 40 patients, and the median and/or ulnar fascicles in 44 patients. A triceps branch was used to restore deltoid function in 25 patients. The level of volitional control achieved was PGS grade 1 in 1 patient (0.6%), grade 2 in 21 patients (13.7%), grade 3 in 103 patients (67.3%), and grade 4 in 28 patients (18.3%). The median PGS grade did not differ significantly between the four donor nerves. No correlations were observed between age, time from BPI to surgery, duration of follow-up, or compliance with rehabilitation and PGS grade. CONCLUSIONS Just around 20% of the authors' patients developed a complete disconnection of the donor program along with complete independent control over the reinnervated muscle. Incomplete disconnection was present in the vast majority of the patients, and the level of disconnection and control was poor in approximately 15% of patients. Brain plasticity underlies patient ability to regain volitional control after a nerve transfer, but this capacity is limited.
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Affiliation(s)
- Mariano Socolovsky
- 1Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Karina Barillaro
- 1Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Gonzalo Bonilla
- 1Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Gilda Di Masi
- 1Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Martijn Malessy
- 2Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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Shin AY, Socolovsky M, Desai K, Fox M, Wang S, Spinner RJ. Differences in management and treatment of traumatic adult pan brachial plexus injuries: a global perspective regarding continental variations. J Hand Surg Eur Vol 2022; 47:40-51. [PMID: 34407694 DOI: 10.1177/17531934211039677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
An expert opinion study was designed to query five countries and six brachial plexus surgeons regarding the demographics, mechanisms of injury, evaluation, timing of surgery, reconstructive strategies and controversies in adult traumatic pan brachial plexus injuries. Variations in assessing outcomes, management of neuropathic pain and future considerations were elucidated. Clear differences in regional demographics, mechanisms of injury, patient evaluation and treatment strategies were identified. The role of phrenic nerve and contralateral C7 transfer, acute use of free functioning muscle transfers, root reimplantation and amputation/myoelectric prosthetic fitting were regional/surgeon dependent. Comparison of outcomes across regions requires an understanding of the regional nuances of patient demographics, injury mechanisms, preferred reconstructive strategies and how outcomes are measured. Future studies are required to allow accurate regional comparisons.
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Affiliation(s)
- Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mariano Socolovsky
- Peripheral Nerve & Plexus Surgery Unit, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Ketan Desai
- Department of Neurosurgery, P D Hinduja Hospital and Medical Research Center, Mumbai, India
| | - Michael Fox
- Peripheral Nerve Injury Unit, The Royal National Orthopaedic Hospital, Stanmore, UK
| | - Shufeng Wang
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China
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Socolovsky M, di Masi G, Bonilla G, Lovaglio A, Krishnan KG. Nerve Graft Length and Recovery of Elbow Flexion Muscle Strength in Patients With Traumatic Brachial Plexus Injuries: Case Series. Oper Neurosurg (Hagerstown) 2021; 20:521-528. [PMID: 33609125 DOI: 10.1093/ons/opab007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/20/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Traumatic brachial plexus injuries cause long-term maiming of patients. The major target function to restore in complex brachial plexus injury is elbow flexion. OBJECTIVE To retrospectively analyze the correlation between the length of the nerve graft and the strength of target muscle recovery in extraplexual and intraplexual nerve transfers. METHODS A total of 51 patients with complete or near-complete brachial plexus injuries were treated with a combination of nerve reconstruction strategies. The phrenic nerve (PN) was used as axon donor in 40 patients and the spinal accessory nerve was used in 11 patients. The recipient nerves were the anterior division of the upper trunk (AD), the musculocutaneous nerve (MC), or the biceps branches of the MC (BBs). An index comparing the strength of elbow flexion between the affected and the healthy arms was correlated with the choice of target nerve recipient and the length of nerve grafts, among other parameters. The mean follow-up was 4 yr. RESULTS Neither the choice of MC or BB as a recipient nor the length of the nerve graft showed a strong correlation with the strength of elbow flexion. The choice of very proximal recipient nerve (AD) led to axonal misrouting in 25% of the patients in whom no graft was employed. CONCLUSION The length of the nerve graft is not a negative factor for obtaining good muscle recovery for elbow flexion when using PN or spinal accessory nerve as axon donors in traumatic brachial plexus injuries.
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Affiliation(s)
- Mariano Socolovsky
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gilda di Masi
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gonzalo Bonilla
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Ana Lovaglio
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Kartik G Krishnan
- Department of Orthopedics, Traumatology and Neurosurgery, Kliniken Frankfurt Main Taunus, Frankfurt, Germany
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Socolovsky M, Malessy M. Brain changes after peripheral nerve repair: limitations of neuroplasticity. J Neurosurg Sci 2021; 65:421-430. [PMID: 33709667 DOI: 10.23736/s0390-5616.21.05298-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neuroplasticity is the capacity of the central nervous system to adapt to external or internal stimuli. It is being increasingly recognized as an important factor which contributes to the successful outcome of nerve transfers. Other much more well-known factors are the number of axons that cross the coaptation site, the interval between trauma and repair, and age. Neuroplasticity is mediated by synaptic and neurotransmitter changes which underlie activation of previously existing but low-active connections in the brain. Dendritic sprouting and axonal elongation might also take place, but is likely less prominent. We review different factors that play a role in neuroplasticity and functional regeneration after specific nerve transfers. These factors include, amongst others, the distance between cortical areas of the donor and receptor neurons; the presence versus absence of pre-existing low-active inter-neuronal connections; gross versus fine movement restoration; rehabilitation; brain trauma and also very important: the age. The potential for plastic adaptation should be taken into consideration if the surgical strategy and post-operative rehabilitation are planned, as its influence on results cannot be denied.
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Affiliation(s)
- Mariano Socolovsky
- Peripheral Nerve & Plexus Surgery Unit, University of Buenos Aires School of Medicine, Buenos Aires, Argentina -
| | - Martijn Malessy
- Department of Neurosurgery, University of Leiden Medical Center, Leiden, the Netherlands
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Doi K, Sem SH, Ghanghurde B, Hattori Y, Sakamoto S. Pearls and Pitfalls of Phrenic Nerve Transfer for Shoulder Reconstruction in Brachial Plexus Injury. J Brachial Plex Peripher Nerve Inj 2021; 16:e1-e9. [PMID: 33584849 PMCID: PMC7875611 DOI: 10.1055/s-0041-1722979] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/12/2020] [Indexed: 11/05/2022] Open
Abstract
Objectives
The purpose of this study was to report the functional outcomes of phrenic nerve transfer (PNT) to suprascapular nerve (SSN) for shoulder reconstruction in brachial plexus injury (BPI) patients with total and C5–8 palsies, and its pulmonary complications.
Methods
Forty-four out of 127 BPI patients with total and C5–8 palsies who underwent PNT to SSN for shoulder reconstruction were evaluated for functional outcomes in comparison with other types of nerve transfers. Their pulmonary function was analyzed using vital capacity in the percentage of predicted value and Hugh-Jones (HJ) breathless classification. The predisposing factors to develop pulmonary complications in those patients were examined as well.
Results
PNT to SSN provided a better shoulder range of motion significantly as compared with nerve transfer from C5 root and contralateral C7. The results between PNT and spinal accessory nerve transfer to SSN were comparable in all directions of shoulder motions. There were no significant respiratory symptoms in majority of the patients including six patients who were classified into grade 2 HJ breathlessness grading. Two predisposing factors for poorer pulmonary performance were identified, which were age and body mass index, with cut-off values of younger than 32 years old and less than 23, respectively.
Conclusions
PNT to SSN can be a reliable reconstructive procedure in restoration of shoulder function in BPI patients with total or C5–8 palsy. The postoperative pulmonary complications can be prevented with vigilant patient selection.
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Affiliation(s)
- Kazuteru Doi
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan
| | - Sei Haw Sem
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan.,Department of Orthopaedics, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Bipin Ghanghurde
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan.,Hand surgery, Kusum Orthopedic Centre, Mumbai, Maharashtra, India.,Hand surgery, Wadia Hospital, Mumbai, Maharashtra, India.,Hand surgery, Surya Hospital, Mumbai, Maharashtra, India
| | - Yasunori Hattori
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan
| | - Sotetsu Sakamoto
- Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi City, Yamaguchi Prefecture, Japan
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El-Gammal TA, El-Sayed A, Kotb MM, Abdel-Hamid UF, El-Gammal YT. Long-Term Outcome of Phrenic Nerve Transfer in Brachial Plexus Avulsion Injuries. Ann Plast Surg 2021; 86:188-192. [PMID: 33346562 DOI: 10.1097/sap.0000000000002611] [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: 10/22/2022]
Abstract
INTRODUCTION In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years. PATIENTS AND METHODS Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years. RESULTS Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms. CONCLUSIONS The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.
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Affiliation(s)
- Tarek Abdalla El-Gammal
- From the Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
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Socolovsky M, Cardoso MDM, Lovaglio A, di Masi G, Bonilla G, de Amoreira Gepp R. Comparison Between Supraclavicular Versus Video-Assisted Intrathoracic Phrenic Nerve Section for Transfer in Patients With Traumatic Brachial Plexus Injuries: Case Series. Oper Neurosurg (Hagerstown) 2020; 19:249-254. [PMID: 32497215 DOI: 10.1093/ons/opaa163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 04/06/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The phrenic nerve has been extensively reported to be a very powerful source of transferable axons in brachial plexus injuries. The most used technique used is supraclavicular sectioning of this nerve. More recently, video-assisted thoracoscopic techniques have been reported as a good alternative, since harvesting a longer phrenic nerve avoids the need of an interposed graft. OBJECTIVE To compare grafting vs phrenic nerve transfer via thoracoscopy with respect to mean elbow strength at final follow-up. METHODS A retrospective analysis was conducted among patients who underwent phrenic nerve transfer for elbow flexion at 2 centers from 2008 to 2017. All data analysis was performed in order to determine statistical significance among the analyzed variables. RESULTS A total of 32 patients underwent supraclavicular phrenic nerve transfer, while 28 underwent phrenic nerve transfer via video-assisted thoracoscopy. Demographic characteristics were similar in both groups. A statistically significant difference in elbow flexion strength recovery was observed, favoring the supraclavicular phrenic nerve section group against the intrathoracic group (P = .036). A moderate though nonsignificant difference was observed favoring the same group in mean elbow flexion strength. Also, statistical differences included patient age (P = .01) and earlier time from trauma to surgery (P = .069). CONCLUSION Comparing supraclavicular sectioning of the nerve vs video-assisted, intrathoracic nerve sectioning to restore elbow flexion showed that the former yielded statistically better results than the latter, in terms of the percentage of patients who achieve at least level 3 MRC strength at final follow-up. Furthermore, larger scale prospective studies assessing the long-term effects of phrenic nerve transfers remain necessary.
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Affiliation(s)
- Mariano Socolovsky
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | | | - Ana Lovaglio
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gilda di Masi
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gonzalo Bonilla
- Nerve & Plexus Surgery Program, Division of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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Socolovsky M, Bonilla G, Lovaglio AC, Masi GD. Differences in strength fatigue when using different donors in traumatic brachial plexus injuries. Acta Neurochir (Wien) 2020; 162:1913-1919. [PMID: 32556814 DOI: 10.1007/s00701-020-04454-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/08/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The purpose of this study was to assess the results of elbow flexion strength fatigue, rather than the maximal power of strength, after brachial plexus re-innervation with phrenic and spinal accessory nerves. We designed a simple but specific test to study whether statistical differences were observed among those two donor nerves. METHOD We retrospectively reviewed patients with severe brachial plexus palsy for which either phrenic nerve (PN) or spinal accessory nerve (SAN) to musculocutaneous nerve (MCN) transfer was performed. A dynamometer was used to determine the maximal contraction strength. One and two kilograms circular weights were utilized to measure isometrically the duration of submaximal and near-maximal contraction time. Statistical analysis was performed between the two groups. RESULTS Twenty-eight patients were included: 21 with a PN transfer while 7 with a SAN transfer for elbow flexion. The mean time from trauma to surgery was 7.1 months for spinal accessory nerve versus 5.2 for phrenic nerve, and the mean follow-up was 57.7 and 38.6 months, respectively. Statistical analysis showed a quicker fatigue for the PN, such that patients with the SAN transfer could hold weights of 1 kg and 2 kg for a mean of 91.0 and 61.6 s, respectively, while patients with transfer of the phrenic nerve could hold 1 kg and 2 kg weights for just a mean of 41.7 and 19.6 s, respectively. Both differences were statistically significant (at p = 0.006 and 0.011, respectively). Upon correlation analysis, endurances at 1 kg and 2 kg were strongly correlated, with r = 0.85 (p < 0.001). CONCLUSIONS Our results suggest that phrenic to musculocutaneous nerve transfer showed an increased muscular fatigue when compared with spinal accessory nerve to musculocutaneous transfer. Further studies designed to analyze this relation should be performed to increase our knowledge about strength endurance/fatigue and muscle re-innervation.
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Affiliation(s)
- Mariano Socolovsky
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina.
| | - Gonzalo Bonilla
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina
| | - Ana Carolina Lovaglio
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina
| | - Gilda di Masi
- Peripheral Nerve & Brachial Plexus Surgery Program, Department of Neurosurgery, Hospital de Clinicas, University of Buenos Aires School of Medicine, 1175 Torre 2 5A, 1428, Buenos Aires, La Pampa, Argentina
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Jia X, Yang J, Yu C. Intercostal nerve transfer for restoration of the diaphragm muscle function after phrenic nerve transfer in total brachial plexus avulsion. Clin Neurol Neurosurg 2020; 197:106085. [PMID: 32683197 DOI: 10.1016/j.clineuro.2020.106085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 11/17/2022]
Abstract
OBJECT To determine the possibility of innervation of the diaphragm muscle using intercostal nerve after ipsilateral phrenic nerve transfer in total brachial plexus avulsion. METHODS Bilateral phrenic nerves and the 9th intercostal nerves were observed inside the thorax. The point where the phrenic nerve entered the diaphragm muscle (point A), the point where the 9th intercostal nerve gave rise to the cutaneous branch (point B) and crossed the posterior axillary line (point C) and the point where the posterior axillary line met the insertion of the diaphragm muscle (point D) were identified. The distances between points B and C, points A and C and from points A through D to C were recorded respectively. The 9th intercostal nerve was transferred to the distal stump of the phrenic nerve in one patient after phrenic nerve transfer to avulsed brachial plexus. RESULTS The mean distances between points B and C, points A and C and from points A through D to C were 12.20 ± 1.04 cm, 10.32 ± 1.02 cm and 16.43 ± 0.91 cm on the right side respectively, 11.78 ± 1.21 cm, 7.77 ± 0.85 cm and 11.74 ± 1.00 cm on the left side respectively. The 9th intercostal nerve was used to innervate the distal stump of the phrenic nerve in one patient after the phrenic nerve transfer to the avulsed brachial plexus. The diaphragm muscle function partially recovered one year after the operation. CONCLUSION The 9th intercostal nerve can be transferred to the distal stump of the phrenic nerve to restore the diaphragm muscle function according to the anatomical study. The movement of the diaphragm muscle was partially restored in one clinical case.
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Affiliation(s)
- Xiaotian Jia
- Department of Hand Surgery, Huashan Hospital, Fudan University, China; Key Laboratory of Hand Reconstruction, Ministry of Health, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, China
| | - Jianyun Yang
- Department of Hand Surgery, Huashan Hospital, Fudan University, China; Key Laboratory of Hand Reconstruction, Ministry of Health, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, China.
| | - Cong Yu
- Department of Hand Surgery, Huashan Hospital, Fudan University, China; Key Laboratory of Hand Reconstruction, Ministry of Health, China; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, China
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Zheng MX, Shen YD, Hua XY, Hou AL, Zhu Y, Xu WD. Cortical Reorganization in Dual Innervation by Single Peripheral Nerve. Neurosurgery 2019; 83:819-826. [PMID: 29029335 DOI: 10.1093/neuros/nyx474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 08/18/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Functional recovery after peripheral nerve injury and repair is related with cortical reorganization. However, the mechanism of innervating dual targets by 1 donor nerve is largely unknown. OBJECTIVE To investigate the cortical reorganization when the phrenic nerve simultaneously innervates the diaphragm and biceps. METHODS Total brachial plexus (C5-T1) injury rats were repaired by phrenic nerve-musculocutaneous nerve transfer with end-to-side (n = 15) or end-to-end (n = 15) neurorrhaphy. Brachial plexus avulsion (n = 5) and sham surgery (n = 5) rats were included for control. Behavioral observation, electromyography, and histologic studies were used for confirming peripheral nerve reinnervation. Cortical representations of the diaphragm and reinnervated biceps were studied by intracortical microstimulation techniques before and at months 0.5, 3, 5, 7, and 10 after surgery. RESULTS At month 0.5 after complete brachial plexus injury, the motor representation of the injured forelimb disappeared. The diaphragm representation was preserved in the "end-to-side" group but absent in the "end-to-end" group. Rhythmic contraction of biceps appeared in "end-to-end" and "end-to-side" groups, and the biceps representation reappeared in the original biceps and diaphragm areas at months 3 and 5. At month 10, it was completely located in the original biceps area in the "end-to-end" group. Part of the biceps representation remained in the original diaphragm area in the "end-to-side" group. Destroying the contralateral motor cortex did not eliminate respiration-related contraction of biceps. CONCLUSION The brain tends to resume biceps representation from the original diaphragm area to the original biceps area following phrenic nerve transfer. The original diaphragm area partly preserves reinnervated biceps representation after end-to-side transfer.
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Affiliation(s)
- Mou-Xiong Zheng
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yun-Dong Shen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Xu-Yun Hua
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Ao-Lin Hou
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yi Zhu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-Dong Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China.,State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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18
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Socolovsky M, Malessy M, Bonilla G, Di Masi G, Conti ME, Lovaglio A. Phrenic to musculocutaneous nerve transfer for traumatic brachial plexus injuries: analyzing respiratory effects on elbow flexion control. J Neurosurg 2019; 131:165-174. [DOI: 10.3171/2018.4.jns173248] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 04/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIn this study, the authors sought to identify the relationship between breathing and elbow flexion in patients with a traumatic brachial plexus injury (TBPI) who undergo a phrenic nerve (PN) transfer to restore biceps flexion. More specifically, the authors studied whether biceps strength and the maximal range of active elbow flexion differ between full inspiration and expiration, and whether electromyography (EMG) activity in the biceps differs between forced maximum breathing during muscular rest, normal breathing during rest, and at maximal biceps contraction. All these variables were studied in a cohort with different intervals of follow-up, as the authors sought to determine if the relationship between breathing movements and elbow flexion changes over time.METHODSThe British Medical Research Council muscle-strength grading system and a dynamometer were used to measure biceps strength, which was measured 1) during a maximal inspiratory effort, 2) during respiratory repose, and 3) after a maximal expiratory effort. The maximum range of elbow flexion was measured 1) after maximal inspiration, 2) during normal breathing, and 3) after maximal expiration. Postoperative EMG testing was performed 1) during normal breathing with the arm at rest, 2) during sustained maximal inspiration with the arm at rest, and 3) during maximal voluntary biceps contraction. Within-group (paired) comparisons, and both correlation and regression analyses were performed.RESULTSTwenty-one patients fit the study inclusion criteria. The mean interval from trauma to surgery was 5.5 months, and the mean duration of follow-up 2.6 years (range 10 months to 9.6 years). Mean biceps strength was 0.21 after maximal expiration versus 0.29 after maximal inspiration, a difference of 0.08 (t = 4.97, p < 0.001). Similarly, there was almost a 21° difference in maximum elbow flexion, from 88.8° after expiration to 109.5° during maximal inspiration (t = 5.05, p < 0.001). Involuntary elbow flexion movement during breathing was present in 18/21 patients (86%) and averaged almost 20°. Measuring involuntary EMG activity in the biceps during rest and contraction, there were statistically significant direct correlations between readings taken during normal and deep breathing, which were moderate (r = 0.66, p < 0.001) and extremely strong (r = 0.94, p < 0.001), respectively. Involuntary activity also differed significantly between normal and deep breathing (2.14 vs 3.14, t = 4.58, p < 0.001). The degrees of involuntary flexion were significantly greater within the first 2.6 years of follow-up than later.CONCLUSIONSThese results suggest that the impact of breathing on elbow function is considerable after PN transfer for elbow function reconstruction following a TBPI, both clinically and electromyographically, but also that there may be some waning of this influence over time, perhaps secondary to brain plasticity. In the study cohort, this waning impacted elbow range of motion more than biceps muscle strength and EMG recordings.
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Affiliation(s)
- Mariano Socolovsky
- 1Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and
| | - Martijn Malessy
- 2Department of Neurosurgery, University of Leiden School of Medicine, Leiden, Holland
| | - Gonzalo Bonilla
- 1Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and
| | - Gilda Di Masi
- 1Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and
| | - María Eugenia Conti
- 3Unit of Neurophysiology, Department of Neurology, University of Buenos Aires School of Medicine, Buenos Aires, Argentina; and
| | - Ana Lovaglio
- 1Peripheral Nerve and Brachial Plexus Surgery Program, Department of Neurosurgery, and
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Sammons VJ, Midha R. Editorial. The breathing arm revisited. J Neurosurg 2019; 131:163-164. [DOI: 10.3171/2018.5.jns181001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Vanessa J. Sammons
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Rajiv Midha
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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20
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Cardoso MDM, Gepp RDA, Mamare E, Guedes-Correa JF. Results of Phrenic Nerve Transfer to the Musculocutaneous Nerve Using Video-Assisted Thoracoscopy in Patients with Traumatic Brachial Plexus Injury: Series of 28 Cases. Oper Neurosurg (Hagerstown) 2018; 17:261-267. [DOI: 10.1093/ons/opy350] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 01/18/2023] Open
Abstract
Abstract
BACKGROUND
The phrenic nerve can be transferred to the musculocutaneous nerve using video-assisted thoracoscopy, aiming at the recovery of elbow flexion in patients with traumatic brachial plexus injuries. There are few scientific papers in the literature that evaluate the results of this operative technique.
OBJECTIVE
To evaluate biceps strength and pulmonary function after the transfer of the phrenic nerve to the musculocutaneous nerve using video-assisted thoracoscopy.
METHODS
A retrospective study was carried out in a sample composed of 28 patients who were victims of traumatic injury to the brachial plexus from 2008 to 2013. Muscle strength was graded using the British Medical Research Council (BMRC) scale and pulmonary function through spirometry. Statistical tests, with significance level of 5%, were used.
RESULTS
In total, 74.1% of the patients had biceps strength greater than or equal to M3. All patients had a decrease in forced vital capacity and forced expiratory volume in 1 s, with no evidence of recovery over time.
CONCLUSION
Transferring the phrenic nerve to the musculocutaneous nerve using video-assisted thoracoscopy may lead to an increase in biceps strength to BMRC M3 or greater in most patients. Considering the deterioration in the parameters of spirometry observed in our patients and the future effects of aging in the respiratory system, it is not possible at the moment to guarantee the safety of this operative technique in the long term.
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Affiliation(s)
| | | | - Eduardo Mamare
- Department of Thoracic Surgery, Sarah Network of Rehabilitation Hospitals, Brasilia, Brazil
| | - José Fernando Guedes-Correa
- Division of Neurosurgery, Gaffree e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
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21
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Jiang Y, Lao J. The phrenic nerve transfer in the treatment of a septuagenarian with brachial plexus avulsion injury: a case report. Int J Neurosci 2017; 128:467-471. [PMID: 29077513 DOI: 10.1080/00207454.2017.1398154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Phrenic nerve transfer has been a well-established procedure for restoring elbow flexion function in patients with brachial plexus avulsion injury. Concerning about probably detrimental respiratory effects brought by the operation, however, stirred up quite a bit of controversy. We present a case report of the successful application of phrenic nerve as donor to reinnervate the biceps in a septuagenarian with brachial plexus avulsion injury, not accompanied with significant clinical respiratory problem.
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Affiliation(s)
- Ye Jiang
- a Department of Hand Surgery, Huashan Hospital , Fudan University , Shanghai , China.,b Key Laboratory of Hand Reconstruction , Ministry of Health , Shanghai , China.,c Shanghai Key Laboratory of Peripheral Nerve and Microsurgery , Shanghai , China
| | - Jie Lao
- a Department of Hand Surgery, Huashan Hospital , Fudan University , Shanghai , China.,b Key Laboratory of Hand Reconstruction , Ministry of Health , Shanghai , China.,c Shanghai Key Laboratory of Peripheral Nerve and Microsurgery , Shanghai , China
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Socolovsky M, di Masi G, Bonilla G, Lovaglio AC, López D. Age as a Predictor of Long-Term Results in Patients with Brachial Plexus Palsies Undergoing Surgical Repair. Oper Neurosurg (Hagerstown) 2017; 15:15-24. [DOI: 10.1093/ons/opx184] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/17/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Among other factors, like the time from trauma to surgery or the number of axons that reach the muscle target, a patient's age might also impact the final results of brachial plexus surgery.
OBJECTIVE
To identify (1) any correlations between age and the 2 outcomes: elbow flexion strength and shoulder abduction range; (2) whether childhood vs adulthood influences outcomes; and (3) other baseline variables associated with surgical outcomes.
METHODS
Twenty pediatric patients (under age 20 yr) who had sustained a traumatic brachial plexus injury were compared against 20 patients, 20 to 29 yr old, and 20 patients, 30 yr old or older. Univariate, univariate trend, and correlation analyses were conducted with patient age, time to surgery, type of injury, and number of injured roots included as independent variables.
RESULTS
A statistically significant trend toward decreasing mean strength in elbow flexion, progressing from the youngest to oldest age group, was observed. This linear trend persisted when subjects were subdivided into 4 age groups (<20, 20-29, 30-39, ≥40). There were no differences by age group in final shoulder abduction range or the percentage achieving a good shoulder outcome.
CONCLUSION
Our data suggest that age is somehow linked to the outcomes of brachial plexus surgery with respect to elbow flexion, but not shoulder abduction strength. Increasing age is associated with steadily worsening elbow flexion outcomes, perhaps indicating the need for earlier surgery and/or more aggressive repairs in older patients.
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Affiliation(s)
- Mariano Socolovsky
- Peripheral Nerve & Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gilda di Masi
- Peripheral Nerve & Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Gonzalo Bonilla
- Peripheral Nerve & Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Ana Carolina Lovaglio
- Peripheral Nerve & Plexus Surgery Unit, Department of Neurosurgery, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Dan López
- Department of Neurosurgery, Hospital Juarez de México, Mexico City, Mexico
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Forli A, Bouyer M, Aribert M, Curvale C, Delord M, Corcella D, Moutet F. Upper limb nerve transfers: A review. HAND SURGERY & REHABILITATION 2017; 36:151-172. [DOI: 10.1016/j.hansur.2016.11.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/19/2016] [Accepted: 11/09/2016] [Indexed: 11/27/2022]
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Socolovsky M, Malessy M, Lopez D, Guedes F, Flores L. Current concepts in plasticity and nerve transfers: relationship between surgical techniques and outcomes. Neurosurg Focus 2017; 42:E13. [PMID: 28245665 DOI: 10.3171/2016.12.focus16431] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Neuroplasticity is analyzed in this article as the capacity of the CNS to adapt to external and internal stimuli. It is being increasingly recognized as an important factor for the successful outcome of nerve transfers. Better-known factors are the number of axons that cross the coaptation site, the time interval between trauma and repair, and age. Neuroplasticity is mediated initially by synaptic and neurotransmitter changes. Over time, the activation of previously existing but lowly active connections in the brain cortex contributes further. Dendritic sprouting and axonal elongation might also take place but are less likely to be prominent. METHODS The authors reviewed different factors that play roles in neuroplasticity and functional regeneration after specific nerve transfers. RESULTS The authors found that these different factors include, among others, the distance between cortical areas of the donor and receptor neurons, the presence versus absence of preexisting lowly active interneuronal connections, gross versus fine movement restoration, rehabilitation, brain trauma, and age. CONCLUSIONS The potential for plasticity should be taken into consideration by surgeons when planning surgical strategy and postoperative rehabilitation, because its influence on results cannot be denied.
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Affiliation(s)
- Mariano Socolovsky
- Peripheral Nerve and Plexus Surgery Unit, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
| | - Martijn Malessy
- Department of Neurosurgery, University of Leiden Medical Center, Leiden, The Netherlands
| | - Dan Lopez
- Department of Neurosurgery, Hospital Juarez de México, México City, México
| | - Fernando Guedes
- Department of Neurosurgery, Hospital Universitário Gaffré e Guinle, Federal University of Rio de Janeiro, Rio de Janeiro; and
| | - Leandro Flores
- Department of Neurosurgery, Hospital das Forças Armadas, Brasília, Brazil
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de Mendonça Cardoso M, Gepp R, Correa JFG. Outcome following phrenic nerve transfer to musculocutaneous nerve in patients with traumatic brachial palsy: a qualitative systematic review. Acta Neurochir (Wien) 2016; 158:1793-800. [PMID: 27260490 DOI: 10.1007/s00701-016-2855-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 05/18/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND The phrenic nerve can be transferred to the musculocutaneous nerve in patients with traumatic brachial plexus palsy in order to recover biceps strength, but the results are controversial. There is also a concern about pulmonary function after phrenic nerve transection. In this paper, we performed a qualitative systematic review, evaluating outcomes after this procedure. METHOD A systematic review of published studies was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Data were extracted from the selected papers and related to: publication, study design, outcome (biceps strength in accordance with BMRC and pulmonary function) and population. Study quality was assessed using the "strengthening the reporting of observational studies in epidemiology" (STROBE) standard or the CONSORT checklist, depending on the study design. RESULTS Seven studies were selected for this systematic review after applying inclusion and exclusion criteria. One hundred twenty-four patients completed follow-up, and most of them were graded M3 or M4 (70.1 %) for biceps strength at the final evaluation. Pulmonary function was analyzed in five studies. It was not possible to perform a statistical comparison between studies because the authors used different parameters for evaluation. Most of the patients exhibited a decrease in pulmonary function tests immediately after surgery, with recovery in the following months. Study quality was determined using STROBE in six articles, and the global score varied from 8 to 21. CONCLUSIONS Phrenic nerve transfer to the musculocutaneous nerve can recover biceps strength ≥M3 (BMRC) in most patients with traumatic brachial plexus injury. Early postoperative findings revealed that the development of pulmonary symptoms is rare, but it cannot be concluded that the procedure is safe because there is no study evaluating pulmonary function in old age.
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Affiliation(s)
- Marcio de Mendonça Cardoso
- Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals, 70673-208, SQSW 302, Brasilia, Brazil.
| | - Ricardo Gepp
- Department of Neurological Surgery, Sarah Network of Rehabilitation Hospitals, 70673-208, SQSW 302, Brasilia, Brazil
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