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Perruisseau-Carrier A, Talagas M, Zhang X, Letissier H, Seizeur R, Hu W. Transfer of the palmaris brevis motor branch to the thenar motor branch: A cadaveric preliminary study. Orthop Traumatol Surg Res 2024; 110:103721. [PMID: 37866508 DOI: 10.1016/j.otsr.2023.103721] [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: 01/17/2023] [Revised: 06/09/2023] [Accepted: 06/22/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE High median nerve injuries can lead to poor distal recovery, especially poor functioning of median innervated thenar muscles involved in thumb opposition and palmar abduction. The palmaris brevis (PB) is a small subcutaneous muscle innervated by ulnar nerve. Innervation of the PB is in most of cases provided by the ulnar digital nerve to the little finger. The purpose of this study is to assess the feasibility of transferring the PB motor branch (PBMB) to the median nerve thenar motor branch (TMB), in order to allow for early restoration of thumb palmar abduction and opposition, through a preliminary cadaveric study. METHODS Twenty-five cadaver upper limbs were dissected under magnification. The length of the PBMB and TMB, and their origin were recorded. Nerve transfer from PBMB to TMB was conducted, and evaluated on 2 parameters: surgical feasibility, and distance from the coaptation site to the recipient nerve muscle entry point. The PBMB and TMB were harvested, fixated in formalin, then embedded in paraffin. They were sectioned transversely, and stained with a combination of hematoxylin-eosin and Luxol fast blue. Myelinated axons were counted in each specimen and the donor-to-recipient axon ratio was recorded. RESULTS The PBMB was constant and originated from the ulnar digital nerve of the little finger in all cases. The transfer from PBMB to TMB was feasible in all cases. Mean myelinated axon counts of PBMB and TMB were 253±142 and 356±198, respectively (p=0.06). The donor-to-recipient axon ratio was 1:1.41. The mean distance from coaptation of the PBMB to the recipient thenar muscles was 23.1±3.0mm. CONCLUSIONS Based on our results, PBMB to TMB transfer is feasible. The PBMB has the advantage over other distal nerve transfer donors to be constant and superficial, allowing for an easier harvest. Moreover, this procedure does not sacrifice any intrinsic function of the hand, and the proximity of the PBMB with the carpal tunnel allows for a single incision procedure. Therefore, early restoration of the median innervated thenar muscles may be feasible by the PBMB to TMB transfer in cases of high median nerve lesions. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anne Perruisseau-Carrier
- Department of Anatomy, University of Western Brittany, Brest, France; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Brest University Hospital, Brest, France.
| | | | - Xinyi Zhang
- Department of Surgery, Nepean Hospital, Sydney, NSW, Australia
| | - Hoel Letissier
- Department of Orthopedic Surgery, Hand Surgery, Brest University Hospital, Brest, France
| | - Romuald Seizeur
- Department of Anatomy, University of Western Brittany, Brest, France; Department of Neurosurgery, Brest University Hospital, Brest, France
| | - Weiguo Hu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Brest University Hospital, Brest, France
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Lubelski D, Halsey J, Suk I, Tuffaha S, Osgood G, Belzberg AJ. Novel Approach of Femur Shortening With Insertion of Expandable Rod to Achieve End-to-End Repair of Sciatic Nerve Laceration. Oper Neurosurg (Hagerstown) 2023; 24:455-459. [PMID: 36701656 DOI: 10.1227/ons.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/29/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Sciatic nerve injuries are challenging for diagnosis and treatment. Particularly in proximally located high-grade injuries, neurorrhaphy often has poor outcomes. Most advocate autologous grafting and some more recently have suggested the value of knee flexion braces to facilitate end-to-end repair. OBJECTIVE To describe a case of femur shortening to facilitate tension-free, end-to-end sciatic nerve neurorrhaphy. METHODS The patient was a 17-year-old man who was injured by the propeller of a motor boat and suffered a series of lacerations to both lower extremities including transection of his right sciatic nerve in the proximal thigh. After extensive mobilization of the nerve, a greater than 7-cm gap was still present. The patient was treated with femur shortening to facilitate end-to-end coaptation. He subsequently had an expandable rod placed which was lengthened 1 mm per day until his leg length was symmetric. RESULTS Within 7 months postoperatively, the patient had an advancing Tinel sign and paresthesias to the dorsum of his foot. Nine months postoperatively, he had early mobility in his plantarflexion. CONCLUSION We present a novel method of femur shortening with insertion of an expandable rod to facilitate direct end-to-end and tension-free sciatic nerve neurorrhaphy in a proximally located injury. Furthermore, larger scale and comparative studies are warranted to further explore this and other techniques.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jordan Halsey
- Department of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Ian Suk
- 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
| | - Greg Osgood
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Brogan DM, Dy CJ, Rioux-Forker D, Wever J, Leversedge FJ. Influences of Repair Site Tension and Conduit Splinting on Peripheral Nerve Reconstruction. Hand (N Y) 2022; 17:1048-1054. [PMID: 33356577 PMCID: PMC9608270 DOI: 10.1177/1558944720974117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We investigated the use of a conduit splinting technique to mitigate tension at the coaptation site of a rodent nerve defect model to determine the optimal reconstruction method for segmental nerve defects. METHODS A rat sciatic nerve segmental defect model was created by excising 5mm of the sciatic nerve unilaterally. Four groups of 10 rats were each reconstructed using 1 of 4 techniques: primary repair, repair with conduit splinting, reverse isograft with conduit splinting, and reverse isograft without splinting. Functional outcomes were assessed at 6 weeks by measurement of Sciatic Functional Index (SFI), and sciatic nerves were harvested at the nonsurvival surgery. Histomorphologic measurements were reported as a value normalized to the average measurements of the control side. The primary outcomes were assessment of nerve continuity and the proportion of nerve fibers in the regenerating nerve compared with the uninjured side. RESULTS The number of repair site rupture rates was lower when a conduit splint was used-less than half of the primary repairs under tension remained intact at 6 weeks. No difference was seen in axon number, size, and density between primary repairs and those augmented by conduit splints, but worse functional outcomes and more debris were present compared with the intact primary repairs. CONCLUSIONS Nerve conduit splinting reduced rupture rates, particularly for nerve repairs associated with a segmental defect. No significant difference was seen in the number of axons among techniques. Primary nerve repair under tension that did not rupture demonstrated superior SFI.
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The Effect of Tension on Gene Expression in Primary Nerve Repair via the Epineural Suture Technique. J Surg Res 2022; 277:211-223. [DOI: 10.1016/j.jss.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 02/17/2022] [Accepted: 03/10/2022] [Indexed: 11/24/2022]
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Bendale GS, Sonntag M, Clements IP, Isaacs JE. Biomechanical Testing of a Novel Device for Sutureless Nerve Repair. Tissue Eng Part C Methods 2022; 28:469-475. [PMID: 35850519 PMCID: PMC9526470 DOI: 10.1089/ten.tec.2022.0080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/14/2022] [Indexed: 11/12/2022] Open
Abstract
Suboptimal nerve end alignment achieved with conventional nerve repair techniques may contribute to poor clinical outcomes. In this study, we introduce Nerve Tape®, a novel nerve repair device that integrates flexible columns of Nitinol microhooks within a biologic backing to entubulate, align, and secure approximated nerve ends. This study compares the repair strength of Nerve Tape with that of conventional microsuture repairs. Thirty small (2 mm) and 30 large (7 mm) diameter human cadaveric nerves were transected and repaired utilizing Nerve Tape or appropriate microsuture technique. Biomechanical testing was performed using a horizontal tensile tester. The repaired nerves were loaded until failure at a distraction rate of 40 mm/min, and the maximum failure load was determined. In the small nerve groups, the load-to-failure for Nerve Tape repairs (2.33 ± 0.66 N) was significantly higher than for suture repairs (1.22 ± 0.52 N; p < 0.05). In the large nerve groups, no significant difference in load-to-failure was found between Nerve Tape (7.45 ± 2.66 N) and suture repairs (5.82 ± 1.59 N: p = 0.12). Suture repairs tended to fail by rupture, whereas Nerve Tape failures resulted from microhook pullout. Nerve Tape is a novel nerve coaptation device that provides mechanical repair strength equal or greater to clinically relevant microsuture repairs.
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Affiliation(s)
- Geetanjali S. Bendale
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | - Jonathan E. Isaacs
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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Nuelle JAV, Bozynski C, Stoker A. Innovations in Peripheral Nerve Injury: Current Concepts and Emerging Techniques to Improve Recovery. MISSOURI MEDICINE 2022; 119:129-135. [PMID: 36036028 PMCID: PMC9339399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Despite the surgical advances in treatment of peripheral nerve injuries, consistent recovery of function is limited suggesting that a multimodal approach is required to optimize nerve regeneration. This approach should include advanced surgical repair techniques, as well as tissue engineering, cellular therapies, and application of local and systemic modulators of neuroregeneration. Further research is needed to advance these therapies from the laboratory to clinical practice, and to further understand how these treatments and techniques can act in concert to optimize functional nerve regeneration.
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Affiliation(s)
- Julia A V Nuelle
- Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine
| | - Chantelle Bozynski
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri - Columbia, Columbia, Missouri
| | - Aaron Stoker
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri - Columbia, Columbia, Missouri
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Post-Operative Assessment of Ulnar Nerve Tension Using Shear-Wave Elastography. Neurol Int 2021; 13:469-476. [PMID: 34564291 PMCID: PMC8482121 DOI: 10.3390/neurolint13030046] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Ulnar nerve compression at the elbow level is the second-most common entrapment neuropathy. The aim of this study was to use shear-wave elastography for the quantification of ulnar nerve elasticity in patients after ulnar nerve decompression with anterior transposition and in the contralateral non-operative side. METHOD Eleven patients with confirmed diagnosis and ulnar nerve decompression with anterior transposition were included and examinations were performed on an AixplorerTM ultrasound system (Supersonic Imagine, Aix-en-Provence, France). RESULTS We observed significant differences at 0-degree (p < 0.001), 45-degree (p < 0.05), 90-degree (p < 0.01) and 120-degree (p < 0.001) elbow flexion in the shear elastic modulus of the ulnar nerve in the operative and non-operative sides. There were no statistically significant differences between the elasticity values of the ulnar nerve after transposition at 0-degree elbow flexion and in the non-operative side at 120-degree elbow flexion (p = 0.39), or in the ulnar nerve after transposition at 120-degree elbow flexion and in the non-operative side at 0-degree elbow flexion (p = 0.09). CONCLUSION Shear-wave elastography has the potential to be used postoperatively as a method for assessing nerve tension noninvasively by the estimation of mechanical properties, such as the shear elastic modulus.
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8
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Bazarek S, Brown JM, Shah SB. Clinical potential of tension-lengthening strategies during nerve repair. Neural Regen Res 2021; 17:779-780. [PMID: 34472468 PMCID: PMC8530125 DOI: 10.4103/1673-5374.322461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Stanley Bazarek
- Department of Neurosurgery, Massachusetts General Hospital/Harvard Medical School; Department of Neurosurgery, Brigham & Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Justin M Brown
- Department of Neurosurgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Sameer B Shah
- Departments of Orthopedic Surgery and Bioengineering, University of California-San Diego, La Jolla, CA, USA
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9
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Orozco E, Masuda K, Shah SB. A guide to reducing adverse outcomes in rabbit models of sciatic nerve injury. Lab Anim Res 2021; 37:13. [PMID: 34001283 PMCID: PMC8127204 DOI: 10.1186/s42826-021-00085-1] [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: 09/01/2020] [Accepted: 01/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background Peripheral nerve damage can have debilitating consequences. Rabbit sciatic nerve transection models allow the effective evaluation of surgical repair strategies for large nerve gaps. Despite advantages in size, ease of handling, and functional utility, rabbits can suffer from a number of side effects that affect animal welfare and the quality of scientific inquiry. Such side-effects, which include pressure ulcers and traumatic damage to the foot, are primarily a consequence of insensitivity of the distal hindlimb following sciatic nerve injury. In this study, we present a number of methodologies for identifying, treating, and preventing unintended adverse effects in rabbit sciatic nerve injury models. Results First, we categorize pressure ulcers according to their severity and describe the deployment of a padded bandaging technique to enable ulcer healing. We also introduce a proactive bandaging approach to reduce the likelihood of pressure ulcer formation. Second, we define phenotypes that distinguish between foot injuries resulting from self-mutilation (autotomy) from those caused by incidental traumatic injury secondary to sensori-motor damage. Finally, we detail an effective strategy to reduce the usage of Elizabethan collars; through a gradual weaning protocol, their usefulness in preventing autotomy is retained, while their propensity to impede rabbit grooming and cause abrasion-injury to the neck region is minimized. Conclusions We suggest that application of these methods offer a practical and systematic approach to avoid adverse side effects associated with rabbit sciatic nerve damage, enabling improved animal welfare and scientific outcomes in a powerful nerve injury model.
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Affiliation(s)
- Elisabeth Orozco
- Research Division, VA San Diego Healthcare System, San Diego, CA, USA
| | - Koichi Masuda
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA, USA
| | - Sameer B Shah
- Research Division, VA San Diego Healthcare System, San Diego, CA, USA. .,Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA, USA. .,Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA.
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10
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Van Nest DS, Kahan DM, Ilyas AM. Polyethylene Glycol Fusion of Nerve Injuries: Review of the Technique and Clinical Applicability. J Hand Microsurg 2020; 13:49-54. [PMID: 33867761 PMCID: PMC8041495 DOI: 10.1055/s-0040-1718651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Traumatic peripheral nerve injuries present a particular challenge to hand surgeons as mechanisms of nerve-healing pose serious limitations to achieving complete functional recovery. The loss of distal axonal segments through Wallerian degeneration results in the loss of neuromuscular junctions and irreversible muscle atrophy. Current methods of repair depend on the outgrowth of proximal nerve fibers following direct end-to-end repair or gap repair techniques. Investigational techniques in nerve repair using polyethylene glycol (PEG) nerve fusion have been shown to bypass Wallerian degeneration by immediately restoring nerve axonal continuity, thus resulting in a rapid and more complete functional recovery. The purpose of this article is to review the current literature surrounding this novel technique for traumatic nerve repair, paying particular attention to the underlying physiology of nerve healing and the current applications of PEG fusion in the laboratory and clinical setting. This article also serves to identify areas of future investigation to further establish validity and feasibility and encourage the translation of PEG fusion into clinical use.
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Affiliation(s)
- Duncan S Van Nest
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - David M Kahan
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Asif M Ilyas
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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11
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Recovery and Regrowth After Nerve Repair: A Systematic Analysis of Four Repair Techniques. J Surg Res 2020; 251:311-320. [DOI: 10.1016/j.jss.2020.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 02/05/2023]
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12
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Howarth HM, Kadoor A, Salem R, Nicolds B, Adachi S, Kanaris A, Lovering RM, Brown JM, Shah SB. Nerve lengthening and subsequent end-to-end repair yield more favourable outcomes compared with autograft repair of rat sciatic nerve defects. J Tissue Eng Regen Med 2019; 13:2266-2278. [PMID: 31670904 DOI: 10.1002/term.2980] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/17/2019] [Accepted: 10/04/2019] [Indexed: 12/31/2022]
Abstract
Outcomes of end-to-end nerve repairs are more successful compared with outcomes of repairs bridged by nerve grafts. However, end-to-end repairs are not always possible for large nerve gaps, as excessive tension may cause catastrophic failure. In this study, we built on previous nerve-lengthening studies to test the hypotheses that gradual lengthening of the proximal stump across a large nerve gap enables an end-to-end repair and such a repair results in more favourable regenerative outcomes than autografts, which represent the gold standard in bridging nerve gaps. To test these, we compared structural and functional outcomes in Lewis rats after repair of sciatic nerve gaps using either autografts or a novel compact internal fixator device, which was used to lengthen proximal nerve stumps towards the distal stump over 2 weeks, prior to end-to-end repair. Twelve weeks after the initial injury, outcomes following nerve lengthening/end-to-end repair were either comparable or superior in every measure compared with repair by autografting. The sciatic functional index was not significantly different between groups at 12 weeks. However, we observed a reduced rate of contracture and corresponding significant increase in paw length in the lengthening group. This functional improvement was consistent with structural regeneration; axonal growth distal to the injury was denser and more evenly distributed compared with the autograft group, suggesting substantial regeneration into both tibial and peroneal branches of the sciatic nerve. Our findings show that end-to-end repairs following nerve lengthening are possible for large gaps and that this strategy may be superior to graft-based repairs.
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Affiliation(s)
- Holly M Howarth
- Department of Bioengineering, University of California, San Diego, La Jolla, CA
| | - Adarsh Kadoor
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA
| | - Rayeheh Salem
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA
| | - Brogan Nicolds
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA
| | - Stephanie Adachi
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA
| | - Achilles Kanaris
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA
| | - Richard M Lovering
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Justin M Brown
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA
| | - Sameer B Shah
- Department of Bioengineering, University of California, San Diego, La Jolla, CA.,Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA.,Research Service, VA San Diego Healthcare System, San Diego, CA
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Tang P, Whiteman DR, Voigt C, Miller MC, Kim H. No Difference in Outcomes Detected Between Decellular Nerve Allograft and Cable Autograft in Rat Sciatic Nerve Defects. J Bone Joint Surg Am 2019; 101:e42. [PMID: 31094986 DOI: 10.2106/jbjs.18.00417] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Nerve injuries with a gap/defect represent a clinical challenge without a clear solution. Reconstruction with cable autografts is a common treatment technique, and repair with decellular nerve allograft is a newer option. The purpose of this study was to compare the functional outcomes of reconstruction with cable autografts with those of matched-diameter decellular nerve allografts to evaluate the relative importance of diameter as well as the autograft-versus-allograft nature of the reconstruction. METHODS A unilateral 10-mm sciatic nerve defect was created in 81 genetically identical male Lewis rats and then repaired with a reverse autograft, 4 or 5 sural nerve cable autografts, or a matched-diameter decellular nerve allograft. In each group, at each time point (12, 16, and 20 weeks), all 9 animals underwent functional testing and 5 of the 9 underwent histologic analysis. Functional testing included bilateral measurements of the isometric tetanic force of the tibialis anterior (primary outcome), the weight of the tibialis anterior, and the gastrocnemius compound muscle action potential (CMAP) latency. Histologic evaluation included an axon count as well as measurement of the axon density, fiber diameter, myelin thickness, and G-ratio. RESULTS The repair groups did not differ significantly in terms of isometric tetanic force, muscle weight, or CMAP latency, but these measurements did differ significantly according to the time after surgery (p < 0.05). The isometric tetanic force percent recovery (width of the 95% confidence interval) for the reverse autograft, cable autograft, and decellular nerve allograft was 57.7% (15.6%), 57.0% (23.4%), and 56.0% (19.7%), respectively, at 12 weeks; 69.1% (14.7%), 65.6% (18.5%), and 65.9% (29.1%) at 16 weeks; and 72.5% (18.2%), 73.7% (25.6%), and 71.8% (22.4%) at 20 weeks. Isometric tetanic force and muscle weight recovery were greater and CMAP latency was shorter at 20 and 16 weeks after surgery than they were at 12 weeks. The treatment type did not affect any of the histologic outcomes. CONCLUSIONS In this animal study, we found that matched-diameter decellular nerve allograft was not significantly different from reverse autograft or cable graft reconstruction in terms of function and histologic outcomes. These findings support decellular nerve allograft as a viable treatment option for nerve reconstruction. CLINICAL RELEVANCE This study showed that decellular nerve allograft was no different from cable or reverse autograft in terms of outcome measures in a rat sciatic nerve defect model. If these results are applicable clinically, it would obviate the need for autograft nerve harvest and its ensuing donor site morbidity.
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Affiliation(s)
- Peter Tang
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniel R Whiteman
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
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14
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Frank K, Englbrecht M, Koban KC, Cotofana SC, Stewart JK, Giunta RE, Schenck TL. Nerve transfer of the anterior interosseous nerve to the thenar branch of the median nerve – an anatomical and histological analysis. J Plast Reconstr Aesthet Surg 2019; 72:751-758. [DOI: 10.1016/j.bjps.2018.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/22/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022]
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Sung J, Sikora-Klak J, Adachi SY, Orozco E, Shah SB. Decoupled epineurial and axonal deformation in mouse median and ulnar nerves. Muscle Nerve 2019; 59:619-628. [PMID: 30697763 DOI: 10.1002/mus.26437] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 01/18/2019] [Accepted: 01/27/2019] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Peripheral nerves accommodate mechanical loads during joint movement. Hypothesized protective features include increased nerve compliance near joints and axonal undulation. How axons perceive nerve deformation is poorly understood. We tested whether nerves increase local axonal undulation in regions of high epineurial strain to protect nerve fibers from strain-induced damage. METHODS Regional epineurial strain was measured near the elbow in median and ulnar nerves of mice expressing axonal fluorescence before and after decompression. Regional axonal tortuosity was quantified under confocal microscopy. RESULTS Nerves showed higher epineurial strain just distal to the medial epicondyle; these differences were eliminated after decompression. Axonal tortuosity also varied regionally; however, unlike in the epineurium, it was greater in proximal regions. DISCUSSION In this study we have proposed a neuromechanical model whereby axons can unravel along their entire length due to looser mechanical coupling to the peri/epineurium. Our findings have major implications for understanding nerve biomechanics and dysfunction. Muscle Nerve 59:619-619, 2019.
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Affiliation(s)
- Jaemyoung Sung
- Division of Biological Sciences, University of California, San Diego, La Jolla, California, USA
- Department of Orthopaedic Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0863, La Jolla, California 92093, USA
| | - Jakub Sikora-Klak
- Department of Orthopaedic Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0863, La Jolla, California 92093, USA
| | - Stephanie Y Adachi
- Division of Biological Sciences, University of California, San Diego, La Jolla, California, USA
- Department of Orthopaedic Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0863, La Jolla, California 92093, USA
| | - Elisabeth Orozco
- Department of Orthopaedic Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0863, La Jolla, California 92093, USA
- Research Division, Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Sameer B Shah
- Department of Orthopaedic Surgery, University of California, San Diego, 9500 Gilman Drive, MC 0863, La Jolla, California 92093, USA
- Research Division, Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Bioengineering, University of California, San Diego, La Jolla, California, USA
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Howarth HM, Alaziz T, Nicolds B, O'Connor S, Shah SB. Redistribution of nerve strain enables end-to-end repair under tension without inhibiting nerve regeneration. Neural Regen Res 2019; 14:1280-1288. [PMID: 30804260 PMCID: PMC6425842 DOI: 10.4103/1673-5374.251338] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
End-to-end repair under no or low tension leads to improved outcomes for transected nerves with short gaps, compared to repairs with a graft. However, grafts are typically used to enable a tension-free repair for moderate to large gaps, as excessive tension can cause repairs to fail and catastrophically impede recovery. In this study, we tested the hypothesis that unloading the repair interface by redistributing tension away from the site of repair is a safe and feasible strategy for end-to-end repair of larger nerve gaps. Further, we tested the hypothesis that such an approach does not adversely affect structural and functional regeneration. In this study, we used a rat sciatic nerve injury model to compare the integrity of repair and several regenerative outcomes following end-to-end repairs of nerve gaps of increasing size. In addition, we proposed the use of a novel implantable device to safely repair end-to-end repair of larger nerve gaps by redistributing tension away from the repair interface. Our data suggest that redistriubution of tension away from the site of repair enables safe end-to-end repair of larger gap sizes. In addition, structural and functional measures of regeneration were equal or enhanced in nerves repaired under tension – with or without a tension redistribution device – compared to tension-free repairs. Provided that repair integrity is maintained, end-to-end repairs under tension should be considered as a reasonable surgical strategy. All animal experiments were performed under the approval of the Institutional Animal Care and Use Committee of University of California, San Diego (Protocol S11274).
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Affiliation(s)
- Holly M Howarth
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA
| | - Turki Alaziz
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, CA, USA
| | - Brogan Nicolds
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, USA
| | - Shawn O'Connor
- School of Exercise and Nutritional Sciences, San Diego State University, San Diego, CA, USA
| | - Sameer B Shah
- Department of Bioengineering, University of California; Department of Orthopaedic Surgery, University of California, San Diego, La Jolla; Research Service, VA San Diego Healthcare System, San Diego, CA, USA
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Bahm J, Gkotsi A, Bouslama S, El-Kazzi W, Schuind F. Direct Nerve Sutures in (Extended) Upper Obstetric Brachial Plexus Repair. J Brachial Plex Peripher Nerve Inj 2017; 12:e17-e20. [PMID: 29134042 PMCID: PMC5680045 DOI: 10.1055/s-0037-1608624] [Citation(s) in RCA: 2] [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: 03/28/2017] [Accepted: 09/15/2017] [Indexed: 11/25/2022] Open
Abstract
Background
In rare, selected cases of severe (extended) upper obstetric brachial plexus palsy (OBPP), after supraclavicular exposure and distal mobilization of the traumatized trunks and careful neuroma excision, we decided to perform direct nerve coaptation with tolerable tension and immobilized the affected arm positioned in adduction and 90-degree elbow flexion for three weeks.
Objectives
We present our surgical technique and preliminary results in a prospective open patient series, including 22 patients (14 right and 8 left side affected) between 2009 and 2016, operated at a mean age of 8.4 months.
Methods
Analysis of functional results after a minimum of 18 months was conducted using the British Medical Research Council (BMRC) scale.
Results
All children reached 60–90° of elbow flexion and 75° of shoulder abduction at already six months after surgery. For those patients having already passed one year post surgery, the mean active shoulder abduction reached 92°, and for those who past the 18 months 124°. We discuss the actual knowledge about nerve coaptation under “reasonable” tension including its advantages and drawbacks.
Conclusion
This technique may be indicated in preoperatively selected cases of (extended) upper OBPP and may give good functional results.
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Affiliation(s)
- J Bahm
- Euregio Reconstructive Microsurgery Unit, Franziskushospital Aachen, Aachen, Germany
| | - A Gkotsi
- Department of Orthopaedics and Traumatology, Université Libre de Bruxelles, Erasme University Hospital, Brussels, Belgium
| | - S Bouslama
- Euregio Reconstructive Microsurgery Unit, Franziskushospital Aachen, Aachen, Germany
| | - W El-Kazzi
- Department of Orthopaedics and Traumatology, Université Libre de Bruxelles, Erasme University Hospital, Brussels, Belgium
| | - F Schuind
- Department of Orthopaedics and Traumatology, Université Libre de Bruxelles, Erasme University Hospital, Brussels, Belgium
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Mackenzie SJ, Yi JL, Singla A, Russell TM, Osterhout DJ, Calancie B. Cauda equina repair in the rat: Part 3. Axonal regeneration across Schwann cell-Seeded collagen foam. Muscle Nerve 2017; 57:E78-E84. [PMID: 28746726 DOI: 10.1002/mus.25751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/12/2017] [Accepted: 07/23/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Treatments for patients with cauda equina injury are limited. METHODS In this study, we first used retrograde labeling to determine the relative contributions of cauda equina motor neurons to intrinsic and extrinsic rat tail muscles. Next, we transected cauda equina ventral roots and proceeded to bridge the proximal and distal stumps with either a type I collagen scaffold coated in laminin (CL) or a collagen-laminin scaffold that was also seeded with Schwann cells (CLSC). Regeneration was assessed by way of serial retrograde labeling. RESULTS After accounting for the axonal contributions to intrinsic vs. extrinsic tail muscles, we noted a higher degree of double labeling in the CLSC group (58.0 ± 39.6%) as compared with the CL group (27.8 ± 16.0%; P = 0.02), but not the control group (33.5 ± 18.2%; P = 0.10). DISCUSSION Our findings demonstrate the feasibility of using CLSCs in cauda equina injury repair. Muscle Nerve 57: E78-E84, 2018.
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Affiliation(s)
- Samuel J Mackenzie
- Department of Neuroscience, Upstate Medical University, Syracuse, New York, USA
| | - Juneyoung L Yi
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Amit Singla
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Thomas M Russell
- Department of Cell and Developmental Biology, Upstate Medical University, Syracuse, New York, USA
| | - Donna J Osterhout
- Department of Cell and Developmental Biology, Upstate Medical University, Syracuse, New York, USA
| | - Blair Calancie
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
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Bhatia A, Doshi P, Koul A, Shah V, Brown JM, Salama M. Contralateral C-7 transfer: is direct repair really superior to grafting? Neurosurg Focus 2017; 43:E3. [DOI: 10.3171/2017.4.focus1794] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
It is not uncommon for a severe traumatic brachial plexus injury to involve all 5 roots, resulting in a flail upper limb. In such cases, surgical reconstruction is often palliative, providing only rudimentary function. Nerve transfers are the mainstay of reconstructive strategies due to the predominance of root avulsions. Consistent results are obtained only for restoration of shoulder stability and elbow flexion, whereas restoring useful hand function remains a challenge. The transfer of the contralateral C-7 (cC-7) is commonly used in an attempt to restore basic hand function, but results are notoriously unreliable and inconsistent. Shu-feng Wang and colleagues recently proposed a potentially more successful permutation of this procedure. They advocated direct approximation of the cC-7 to the lower trunk on the paralyzed side, thus avoiding the interposition of nerve grafts. This technique involves a lengthy dissection of the cC-7 transfer across the midline via a prespinal route, as well as extensive mobilization of the ipsilateral lower trunk by cutting a subset of its branches, adducting the arm, and (if necessary) shortening the humerus. Each of these steps is indispensable to achieve direct approximation of the nerve ends. Many surgeons have tried to emulate Wang’s strategy. However, the technical difficulties involved have forced recourse to interposition of nerve grafts once again.The authors report their observations in the first 22 patients in whom they performed this procedure. Direct cC-7 repair via the prespinal route was performed in 12 patients. Shortening of the humerus was necessary in 9 of these 12 patients. In 10 patients, a direct repair was not feasible and nerve grafting was performed. The median follow-up period was 26 months for the direct coaptation group and 28.5 months for the nerve graft group.In the direct repair group, 10 of the 12 patients regained Medical Research Council Grade 3 flexion of the wrist and of the middle, ring, and little fingers, while the remaining 2 patients had Grade 2 function. Flexion appeared 12–14 months after the operation. At the latest follow-up, these patients could activate the wrist and hand without requiring significant augmentation maneuvers in the donor limb. In contrast, repair requiring interposition grafts resulted in Grade 3 strength in only 2 of 10 patients, while 7 had Grade 2 strength, and 1 experienced failure. In all grafted cases, the patient had to forcibly contract the contralateral pectoralis major and triceps muscles to produce the weak movements on the reconstructed side.In this small series, the authors demonstrated a distinct advantage associated with the avoidance of grafts when transferring the cC-7 to restore hand function. The authors conclude that efforts to achieve direct approximation of the donor C-7 and the recipient lower trunk are necessary and justified.
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Affiliation(s)
- Anil Bhatia
- 1Department of Brachial Plexus Surgery, Deenanath Mangeshkar Hospital, Pune
| | - Piyush Doshi
- 2Department of Plastic Surgery, SBKS Medical Institute and Research Centre, Vadodara
| | - Ashok Koul
- 3Department of Plastic Surgery, Sparsh Hospital, Bengaluru
| | - Vitrag Shah
- 4Department of Plastic Surgery, Shah Hospital, Surat, India
| | - Justin M. Brown
- 5Department of Neurosurgery, UC San Diego Health, San Diego, California; and
| | - Mahmoud Salama
- 6Department of Orthopaedics, Aswan University, Aswan, Egypt
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20
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Love JM, Bober BG, Orozco E, White AT, Bremner SN, Lovering RM, Schenk S, Shah SB. mTOR regulates peripheral nerve response to tensile strain. J Neurophysiol 2017; 117:2075-2084. [PMID: 28250148 PMCID: PMC5434482 DOI: 10.1152/jn.00257.2016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 02/09/2017] [Accepted: 02/25/2017] [Indexed: 01/26/2023] Open
Abstract
While excessive tensile strain can be detrimental to nerve function, strain can be a positive regulator of neuronal outgrowth. We used an in vivo rat model of sciatic nerve strain to investigate signaling mechanisms underlying peripheral nerve response to deformation. Nerves were deformed by 11% and did not demonstrate deficits in compound action potential latency or amplitude during or after 6 h of strain. As revealed by Western blotting, application of strain resulted in significant upregulation of mammalian target of rapamycin (mTOR) and S6 signaling in nerves, increased myelin basic protein (MBP) and β-actin levels, and increased phosphorylation of neurofilament subunit H (NF-H) compared with unstrained (sham) contralateral nerves (P < 0.05 for all comparisons, paired two-tailed t-test). Strain did not alter neuron-specific β3-tubulin or overall nerve tubulin levels compared with unstrained controls. Systemic rapamycin treatment, thought to selectively target mTOR complex 1 (mTORC1), suppressed mTOR/S6 signaling, reduced levels of MBP and overall tubulin, and decreased NF-H phosphorylation in nerves strained for 6 h, revealing a role for mTOR in increasing MBP expression and NF-H phosphorylation, and maintaining tubulin levels. Consistent with stretch-induced increases in MBP, immunolabeling revealed increased S6 signaling in Schwann cells of stretched nerves compared with unstretched nerves. In addition, application of strain to cultured adult dorsal root ganglion neurons showed an increase in axonal protein synthesis based on a puromycin incorporation assay, suggesting that neuronal translational pathways also respond to strain. This work has important implications for understanding mechanisms underlying nerve response to strain during development and regeneration.NEW & NOTEWORTHY Peripheral nerves experience tensile strain (stretch) during development and movement. Excessive strain impairs neuronal function, but moderate strains are accommodated by nerves and can promote neuronal growth; mechanisms underlying these phenomena are not well understood. We demonstrated that levels of several structural proteins increase following physiological levels of nerve strain and that expression of a subset of these proteins is regulated by mTOR. Our work has important implications for understanding nerve development and strain-based regenerative strategies.
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Affiliation(s)
- James M Love
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland
| | - Brian G Bober
- Department of Bioengineering, University of California-San Diego, La Jolla, California
| | - Elisabeth Orozco
- Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, California.,Veterans Affairs San Diego Healthcare System, San Diego, California; and
| | - Amanda T White
- Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, California
| | - Shannon N Bremner
- Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, California.,Veterans Affairs San Diego Healthcare System, San Diego, California; and
| | - Richard M Lovering
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Simon Schenk
- Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, California
| | - Sameer B Shah
- Department of Bioengineering, University of California-San Diego, La Jolla, California; .,Department of Orthopaedic Surgery, University of California-San Diego, La Jolla, California.,Veterans Affairs San Diego Healthcare System, San Diego, California; and
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21
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Klein S, Prantl L, Vykoukal J, Loibl M, Felthaus O. Differential Effects of Coating Materials on Viability and Migration of Schwann Cells. MATERIALS 2016; 9:ma9030150. [PMID: 28773276 PMCID: PMC5456653 DOI: 10.3390/ma9030150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 02/19/2016] [Accepted: 02/24/2016] [Indexed: 12/05/2022]
Abstract
Synthetic nerve conduits have emerged as an alternative to guide axonal regeneration in peripheral nerve gap injuries. Migration of Schwann cells (SC) from nerve stumps has been demonstrated as one essential factor for nerve regeneration in nerve defects. In this experiment, SC viability and migration were investigated for various materials to determine the optimal conditions for nerve regeneration. Cell viability and SC migration assays were conducted for collagen I, laminin, fibronectin, lysine and ornithine. The highest values for cell viability were detected for collagen I, whereas fibronectin was most stimulatory for SC migration. At this time, clinically approved conduits are based on single-material structures. In contrast, the results of this experiment suggest that material compounds such as collagen I in conjunction with fibronectin should be considered for optimal nerve healing.
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Affiliation(s)
- Silvan Klein
- Center for Plastic-, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg 93053, Germany.
| | - Lukas Prantl
- Center for Plastic-, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg 93053, Germany.
| | - Jody Vykoukal
- Translational Molecular Pathology, University of Texas MD, Unit 951, 7435 Fannin Street, Houston, TX 77054, USA.
| | - Markus Loibl
- Department of Traumatology, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg 93053, Germany.
| | - Oliver Felthaus
- Center for Plastic-, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, Regensburg 93053, Germany.
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22
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Choudhry IK, Bracey DN, Hutchinson ID, Li Z. Comparison of transposition techniques to reduce gap associated with high ulnar nerve lesions. J Hand Surg Am 2014; 39:2460-3. [PMID: 25300990 DOI: 10.1016/j.jhsa.2014.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 08/22/2014] [Accepted: 08/26/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine in a cadaveric model which of 3 anterior transposition techniques allows for maximum gap reduction for high ulnar nerve lesions. METHODS Six fresh-frozen human adult upper extremity cadaveric transhumeral specimens were used. We anchored the ulnar nerve to bone 10 cm proximal and distal to the medial epicondyle along its exact course while keeping the elbow in 30° flexion as the baseline measurement. We then used a thick suture to mimic and measure the exact course of the nerve between the pins in varying elbow positions. The nerve was then transposed first subcutaneously, then intramuscularly, and then submuscularly while taking exact measurements of the distance the nerve had to travel in varying degrees of elbow flexion for each transposition method. We performed comparative analysis to analyze gap reduction with respect to transposition method and elbow position. RESULTS Transposing the ulnar nerve reduced the repair gap required to cross the elbow regardless of transposition technique. When comparing individual techniques, however, the greatest gap reduction was achieved by intramuscular, followed by submuscular and finally subcutaneous transposition. A maximum gap reduction of 25 mm (average, 23 mm) was achieved using intramuscular transposition with the elbow in 90° flexion. Subcutaneous transposition actually increased the repair gap when the elbow was in an extended position. CONCLUSIONS An intramuscular transposition with the elbow in 90° flexion provided the best gap reduction. However, post-neurorrhaphy mobilization may compromise repair site integrity and vascularity if elbow flexion is required to achieve a primary repair, and these factors should be considered carefully when planning treatment. CLINICAL RELEVANCE This study provides guidance on techniques to reduce nerve gap for primary repair of the ulnar nerve at the elbow using transposition and elbow flexion.
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Affiliation(s)
- Imran K Choudhry
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Daniel N Bracey
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Ian D Hutchinson
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC.
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Use of vein conduit and isolated nerve graft in peripheral nerve repair: a comparative study. PLASTIC SURGERY INTERNATIONAL 2014; 2014:587968. [PMID: 25405029 PMCID: PMC4227328 DOI: 10.1155/2014/587968] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 10/07/2014] [Indexed: 11/30/2022]
Abstract
Aims and Objectives. The aim of this study was to evaluate the effectiveness of vein conduit in nerve repair compared with isolated nerve graft. Materials and Methods. This retrospective study was conducted at author's centre and included a total of 40 patients. All the patients had nerve defect of more than 3 cm and underwent nerve repair using nerve graft from sural nerve. In 20 cases, vein conduit (study group) was used whereas no conduit was used in other 20 cases. Patients were followed up for 2 years at the intervals of 3 months. Results. Patients had varying degree of recovery. Sensations reached to all the digits at 1 year in study groups compared to 18 months in control group. At the end of second year, 84% patients of the study group achieved 2-point discrimination of <10 mm compared to 60% only in control group. In terms of motor recovery, 82% patients achieved satisfactory hand function in study group compared to 56% in control group (P < .05). Conclusions. It was concluded that the use of vein conduit in peripheral nerve repair is more effective method than isolated nerve graft providing good sensory and motor recovery.
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Love JM, Chuang TH, Lieber RL, Shah SB. Nerve strain correlates with structural changes quantified by fourier analysis. Muscle Nerve 2013; 48:433-5. [DOI: 10.1002/mus.23809] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2013] [Indexed: 11/09/2022]
Affiliation(s)
- James M. Love
- Fischell Department of Bioengineering; University of Maryland; College Park; Maryland; USA
| | - Ting-Hsien Chuang
- Departments of Orthopedic Surgery and Bioengineering; University of California; 9500 Gilman Drive, Mail Code 0863; San Diego, La Jolla; California; 92093; USA
| | - Richard L. Lieber
- Departments of Orthopedic Surgery and Bioengineering; University of California; 9500 Gilman Drive, Mail Code 0863; San Diego, La Jolla; California; 92093; USA
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25
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Kechele PR, Bertelli JA, Dalmarco EM, Fröde TS. The mesh repair: Tension free alternative on dealing with nerve gaps-experimental results. Microsurgery 2011; 31:551-8. [DOI: 10.1002/micr.20902] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 02/28/2011] [Accepted: 03/03/2011] [Indexed: 11/06/2022]
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26
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Bustamante J, Socolovsky M, Martins RS, Emmerich J, Pennini MG, Lausada N, Domitrovic L. Effects of eliminating tension by means of epineural stitches: a comparative electrophysiological and histomorphometrical study using different suture techniques in an animal model. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 69:365-70. [DOI: 10.1590/s0004-282x2011000300019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/23/2010] [Indexed: 11/22/2022]
Abstract
Epineural stitches are a means to avoid tension in a nerve suture. We evaluate this technique, relative to interposed grafts and simple neurorraphy, in a rat model. METHOD: Twenty rats were allocated to four groups. For Group 1, sectioning of the sciatic nerve was performed, a segment 4 mm long discarded, and epineural suture with distal anchoring stitches were placed resulting in slight tension neurorraphy. For Group 2, a simple neurorraphy was performed. For Group 3, a 4 mm long graft was employed and Group 4 served as control. Ninety days after, reoperation, latency of motor action potentials recording and axonal counts were performed. Inter-group comparison was done by means of ANOVA and the non-parametric Kruskal-Wallis test. RESULTS: The mean motor latency for the simple suture (2.27±0.77 ms) was lower than for the other two surgical groups, but lower than among controls (1.69±0.56 ms). Similar values were founding in both group 1 (2.66±0.71 ms) and group 3 (2.64±0.6 ms). When fibers diameters were compared a significant difference was identified between groups 2 and 3 (p=0.048). CONCLUSION: Good results can be obtained when suturing a nerve employ with epineural anchoring stitches. However, more studies are needed before extrapolating results to human nerve sutures.
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Affiliation(s)
| | | | - R S Martins
- University of São Paulo; Hospital do Servidor Público do Estado, Brazil
| | - J Emmerich
- Hospital de Pediatría Sor María Ludovica, Argentina
| | - M G Pennini
- Hospital de Pediatría Sor María Ludovica, Argentina
| | - N Lausada
- National University of La Plata, Argentina
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28
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S Mcdonald D, Sg Bell M. Peripheral Nerve Gap Repair Facilitated By a Dynamic Tension Device. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2010. [DOI: 10.1177/229255031001800108] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
End-to-end neurorrhaphy remains the gold standard for transected nerve repair. However, the current dogma is that to be successful, nerve repairs must be tension free. Therefore, nerve gaps are most commonly repaired with grafts. While there is evidence that nerves can regenerate successfully after initial approximation under a tensile force, the amount of tension that deters regeneration of human nerves remains unclear. The present paper describes a case in which a favourable functional outcome was obtained following repair of a median nerve gap that was reduced by a dynamic tension device. The case provides some evidence that modest separations between stumps can be overcome by dynamic tension, enabling primary end-to-end repair of nerve gaps.
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Affiliation(s)
| | - Michael Sg Bell
- Department of Surgery, Division of Plastic Surgery, the Ottawa Hospital – Civic Campus, Ottawa, Ontario
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30
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Jiang B, Zhang P, Yan J, Zhang H. Dynamic Observation of Biomechanic Properties of Sciatic Nerve at the Suture Site in Rats Following Repairing. ACTA ACUST UNITED AC 2009; 36:45-50. [DOI: 10.1080/10731190701857777] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bushnell BD, McWilliams AD, Whitener GB, Messer TM. Early clinical experience with collagen nerve tubes in digital nerve repair. J Hand Surg Am 2008; 33:1081-7. [PMID: 18762101 DOI: 10.1016/j.jhsa.2008.03.015] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 03/22/2008] [Accepted: 03/26/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE In cases of digital nerve injury in which nerve ends cannot be approximated without tension, autologous nerve grafts represent the most commonly used method for reconstruction. Recently, interest in synthetic nerve guides as an alternative to grafting has increased. Although several basic science studies have shown promise for collagen tubes, clinical studies of their success in humans are limited. The purpose of this study was to review our early clinical experience with collagen nerve tubes. METHODS The authors identified and followed all cases involving digital nerve repair at our institution over a 2-year period. Twelve patients had repair of a digital nerve with a collagen nerve tube during the study period. Two patients were lost to follow-up, and 1 patient had amputation of the grafted finger secondary to complications of other injuries. The primary outcome data points for the remaining 9 patients were the static 2-point discrimination (2PD), Semmes-Weinstein monofilament testing, and a Quick Disabilities of the Arm, Shoulder, and Hand (DASH) outcome survey at final follow-up. RESULTS Nine patients had follow-up of at least 1 year, with an average follow-up time of 15 months (range 12-22 months). There were no intraoperative or postoperative complications related to the nerve tubes. Using modified American Society for Surgery of the Hand guidelines, 2PD results were good or excellent in 8 out of 9 of patients. Semmes-Weinstein testing results were full in 5 patients, diminished light touch in 2, diminished protective sensation in 1, and loss of protective sensation in 1. Average Quick DASH scores for the group were 10.86 overall, 4.86 for the work module, and 23.21 for the sports/performing arts module. CONCLUSIONS Although the patients in this study are still within the early follow-up period, our initial results compare favorably with those reported in the existing literature for various types of nerve repair and reconstruction, suggesting that collagen nerve tubes might offer a clinically effective option for restoration of sensory function. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Brandon D Bushnell
- Department of Orthopaedic Surgery, University of North Carolina Hospitals, Chapel Hill, NC 27599-7055, USA.
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Portincasa A, Gozzo G, Parisi D, Annacontini L, Campanale A, Basso G, Maiorella A. Microsurgical treatment of injury to peripheral nerves in upper and lower limbs: a critical review of the last 8 years. Microsurgery 2007; 27:455-62. [PMID: 17596860 DOI: 10.1002/micr.20382] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Nerve injuries to the upper and inferior limbs represent a common event due both to home and working accidents. Minor traumas can lead to severe disabilities if a wrong treatment is carried out. From 1997 to 2005, 920 patients were observed with a total of 1,200 major or minor nerves injuries operated. In 852 cases acute lesions treated. In 68 patients we reviewed old injuries. In 707 patients direct nerve suture and in 145 patients nerve grafts were carried out. One to 8 years follow up observed. Different protocols were adopted according to the injury: simple cut, complex lesion or surgical revision. Results were evaluated during the follow up period with different models: motor evaluation in six levels (BMRC), sensitive evaluation in five levels (HIGHET), and global evaluation with four grades (from the worst to the best result). Nerve healing is a complex biological phenomenon influenced by many parameters related both to the patient characteristics and nerve lesion. Functional and esthetical outcomes vary also according to: age, cultural and economic condition, health status, and smoking. Post operative rehabilitation is mandatory to obtain an acceptable functional result. Nerve injuries to the upper and inferior limbs represent a challenge for the microsurgeon. Ultimate success in nerve surgery is judged by functional as well as cosmetic parameters. Only patients with the appropriate indication should be operated and always by a skilled surgeon.
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Affiliation(s)
- A Portincasa
- Department of Plastic and Reconstructive Surgery, University of Foggia, Foggia, Italy.
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33
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Abstract
Digital nerve injuries in the hand are common and can result in significant impairment and functional restriction. Despite this, there is relatively little literature, particularly with respect to postoperative rehabilitation. Splinting after repair, purported to protect the repaired nerve from excessive stretch is still commonly used. Recent cadaveric studies indicate postoperative rehabilitation is not necessary with resection up to 2.5mm. A randomized controlled trial was therefore undertaken to determine whether splinting after isolated 5th degree digital nerve transection is in fact necessary. Twenty-six subjects were recruited over a two-year period and randomized to either three weeks of hand-based splinting or free active motion. ANCOVA indicated no differences in sensibility at six months between the two groups. Subjects also reported their greatest functional limitations were because of hyperesthesia. Although this study is underpowered, these limited results suggest splinting may not be required postoperatively.
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Affiliation(s)
- Nicole Vipond
- Rehabilitation Teaching and Research Unit, Wellington School of Medicine & Health Sciences, Otago University, Wellington, New Zealand.
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Clavijo-Alvarez JA, Nguyen VT, Santiago LY, Doctor JS, Lee WPA, Marra KG. Comparison of Biodegradable Conduits within Aged Rat Sciatic Nerve Defects. Plast Reconstr Surg 2007; 119:1839-1851. [PMID: 17440364 DOI: 10.1097/01.prs.0000260232.43019.a0] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Considering that little is known about the peripheral nerve regenerative capacity of elderly patients, the authors studied nerve regenerative capacity in aged rats and compared the effect of three synthetic nerve guides with different material characteristics and porosity. The authors hypothesized that the use of a biodegradable composite nerve guide (CultiGuides) would promote nerve regeneration and functional recovery in a manner similar to treatment with autografts or U.S. Food and Drug Administration-approved polyglycolic acid Neurotubes in an aged rat sciatic nerve defect model. METHODS Aged Sprague-Dawley rats (11 months old) underwent a 1-cm sciatic nerve resection in the right leg [group 1, control (contralateral leg samples), n = 10; group 2, negative (nerve gap defect), n = 6; group 3, autograft, n = 10; group 4, polycaprolactone, n = 10; group 5, CultiGuides, n = 10; and group 6, Neurotube, n = 10]. RESULTS After 12 weeks, the negative group did not demonstrate any nerve regeneration. In the regenerated and distal nerve, all treated groups had increased myelinated areas compared with the negative control. In the regenerated nerve, there was a significant increase in myelination in the Neurotube group compared with the polycaprolactone group (p < 0.001). However, in the distal nerve, there were no differences among the treatment groups. Walking track analyses and gastrocnemius muscle weight ratios were not different among treatment groups 3 through 6. CONCLUSIONS The results showed differences in myelination; Neurotubes promoted the highest degree of myelination (p < 0.001) as compared with all groups. The authors found no improvement in function of the repaired nerve as measured by percentage of autotomy, the sciatic function index, and gastrocnemius muscle weight. No group was able to recover function in this aged model.
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Affiliation(s)
- Julio A Clavijo-Alvarez
- Pittsburgh, Pa. From the Division of Plastic and Reconstructive Surgery and Department of Bioengineering, University of Pittsburgh; Department of Biological Sciences, Duquesne University; and McGowan Institute for Regenerative Medicine
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35
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Yoshitani M, Fukuda S, Itoi SI, Morino S, Tao H, Nakada A, Inada Y, Endo K, Nakamura T. Experimental repair of phrenic nerve using a polyglycolic acid and collagen tube. J Thorac Cardiovasc Surg 2007; 133:726-32. [PMID: 17320572 DOI: 10.1016/j.jtcvs.2006.08.089] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 08/12/2006] [Accepted: 08/30/2006] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The feasibility of a nerve guide tube for regeneration of the phrenic nerve with the aim of restoring diaphragmatic function was evaluated in a canine model. METHODS The nerve tube, made of woven polyglycolic acid mesh, had a diameter of 3 mm and was filled with collagen sponge. This polyglycolic acid-collagen tube was implanted into a 10-mm gap created by transection of the right phrenic nerve in 9 beagle dogs. The tubes were implanted without a tissue covering in 5 of the 9 dogs (group I), and the tubes were covered with a pedicled pericardial fat pad in 4 dogs (group II). Chest x-ray films, muscle action potentials, and histologic samples were examined 4 to 12 months after implantation. RESULTS All of the dogs survived without any complications. x-ray film examination showed that the right diaphragm was paralyzed and elevated in all dogs until 3 months after implantation. At 4 months, movement of the diaphragm in the implanted side was observed during spontaneous breathing in 1 dog of group I and in 3 dogs of group II. In the dogs showing diaphragm movement, muscle action potentials were evoked in the diaphragm muscle, indicating restoration of nerve function. Regeneration of the phrenic nerve structure was also examined on the reconstructed site using electron microscopy. CONCLUSION The polyglycolic acid-collagen tube induced functional recovery of the injured phrenic nerve and was aided by coverage with a pedicled pericardial fat pad.
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Affiliation(s)
- Makoto Yoshitani
- Department of Bioartificial Organs, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
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36
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Ruggieri MR, Braverman AS, D'Andrea L, Simpkiss B, Kozin SH, Pontari MA, Betz R, Barbe MF. Functional reinnervation of the canine bladder after spinal root transection and immediate end-on-end repair. J Neurotrauma 2006; 23:1125-36. [PMID: 16866625 PMCID: PMC3285498 DOI: 10.1089/neu.2006.23.1125] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The goal of this study was to transect and immediately repair ventral roots, selected by their ability to stimulate bladder contraction, to assess the feasibility of bladder reinnervation in a canine model. Brain-derived neurotrophic factor (BDNF) was delivered via an osmotic pump (0.5 or 5 mg/mL) to a cuff surrounding the reanastomosis site to the two root bundles on one side. Electrodes were implanted bilaterally immediately proximal to the site of surgical reanastomosis. Results were compared to four root-intact, control animals that also received bilateral electrode implantation. At 6-12 months post-surgery, five of eight nerve transected and repaired animals showed increased pressure and bladder emptying during electrical stimulation of the repaired ventral roots contralateral to the BDNF delivery side. Nerve tracing studies one year postoperatively determined the repaired roots to be S1 and S2 and showed regrowth of axons from the spinal cord to nerve sites proximal to the repair site and to the bladder, and the presence of neurofilament-labeled axons growing across the ventral root repair site. In conclusion, transected ventral and dorsal roots in the sacral spine can be repaired and are capable of functionally reinnervating the urinary bladder. This feasibility study paves the way for future studies utilizing other more proximal motor nerves to bypass the transection site for bladder reinnervation.
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Affiliation(s)
- Michael R Ruggieri
- Department of Urology, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
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37
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Battiston B, Geuna S, Ferrero M, Tos P. Nerve repair by means of tubulization: literature review and personal clinical experience comparing biological and synthetic conduits for sensory nerve repair. Microsurgery 2005; 25:258-67. [PMID: 15934044 DOI: 10.1002/micr.20127] [Citation(s) in RCA: 269] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Nerve repair is usually accomplished by direct suture when the two stumps can be approximated without tension. In the presence of a nerve defect, the placement of an autologous nerve graft is the current gold standard for nerve restoration. However, over the last 20 years, an increasing number of research articles reported on the use of non-nervous tubes (tubulization) for repairing nerve defects. The clinical employment of tubes (both biological and synthetic) as an alternative to autogenous nerve grafts is mainly justified by the limited availability of donor tissue for nerve autografts and the related morbidity. In addition, tubulization was proposed as an alternative to direct nerve sutures in order to create optimal conditions for nerve regeneration over the short empty space intentionally left between two nerve stumps. This paper outlines recent important advances in this field. Different tubulization techniques proposed so far are described, focusing in particular on studies that reported on the employment of tubes with patients. Our personal clinical experience on tubulization repair of sensory nerve lesions (digital nerves), using both biological and synthetic tubes, is presented, and the clinical results are compared. In our case series, both types of tubes led to good clinical results. Finally, we speculate about the prospects in the clinical application of tubulization for peripheral nerve repair.
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Affiliation(s)
- Bruno Battiston
- UOD Reconstructive Microsurgery, Department of Orthopedics, C.T.O. Hospital, Turin, Italy.
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38
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Sunderland IRP, Brenner MJ, Singham J, Rickman SR, Hunter DA, Mackinnon SE. Effect of tension on nerve regeneration in rat sciatic nerve transection model. Ann Plast Surg 2005; 53:382-7. [PMID: 15385776 DOI: 10.1097/01.sap.0000125502.63302.47] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Excessive tension across a nerve repair is known to impair nerve regeneration. However, it is uncertain whether nerve grafting is necessary when end-to-end repair would result in only mild to moderate tension. This study investigated the effect of tension on nerve regeneration. Sciatic nerves of 48 Lewis rats were transected and then repaired primarily after resection of 0-, 3-, 6-, or 9-mm lengths of nerve. Postoperative tension levels were quantified using a tensometer. Robust nerve regeneration was observed at 4 weeks in all except the 9-mm repair group, which showed lower nerve fiber counts, percent neural tissue, and nerve density (P < 0.05) and decreased functional recovery. These data indicate that modest levels of tension are well tolerated, but nerve regeneration drops precipitously once a critical tension threshold is exceeded. This threshold was between 0.39 and 0.56 N in the model studied, corresponding to a nerve defect between 6 mm and 9 mm.
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Affiliation(s)
- Ian R P Sunderland
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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39
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Meek MF, Coert JH, Robinson PH. Poor results after nerve grafting in the upper extremity: Quo vadis? Microsurgery 2005; 25:396-402. [PMID: 16032723 DOI: 10.1002/micr.20137] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The clinical success of peripheral nerve grafting in the upper extremity was evaluated retrospectively in 41 patients. This study comprises a 10-year follow-up in a single institution. Donor and acceptor site morbidity as well as functional nerve recovery were evaluated. Thirty-one men and 10 women were included. Autologous nerve grafts were used for reconstruction of digital nerves in 17 patients, ulnar nerves in 12 patients, median nerves in 10 patients, radial nerve in 1 patient, and both the radial and median nerve in 1 patient. The length of nerve grafts ranged from 1-12.5 cm (mean, 4.8 cm). The follow-up period ranged from 18 months to 10 years. Acceptor site-related problems were noted in 51%% (n = 21) of patients. Donor-site morbidity was seen in 4 patients (10%%). The return of function was scored as "good" in 3 (7%%), "fair" in 11 (27%%), and "bad" in 27 (66%%) patients. The outcome of autologous nerve grafts in this small group of patients treated by several surgeons was unfavorable in terms of function. Recent experimental and clinical studies with biodegradable nerve guides for the repair of peripheral nerve gaps showed superior results in comparison to classic nerve grafts.
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Affiliation(s)
- M F Meek
- Department of Plastic Surgery, University Hospital Groningen, Groningen, The Netherlands.
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40
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Rowshan K, Jones NF, Gupta R. Current surgical techniques of peripheral nerve repair. ACTA ACUST UNITED AC 2004. [DOI: 10.1053/j.oto.2004.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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41
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Takagi T, Nakao Y, Takayama S, Toyama Y. Traction injury of common peroneal nerve associated with multiple ligamentous rupture of the knee: a case report. Microsurgery 2003; 22:339-42. [PMID: 12497569 DOI: 10.1002/micr.10069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report on a case of a 19-year-old male student who sustained a hyperextension injury to his left knee while playing rugby, which resulted in a traction injury of the common peroneal nerve and multiple ligamentous injuries at the knee joint. The damaged part of the common peroneal nerve was resected, and an end-to-end suture was performed, because the gap between the nerve ends was small enough to allow closure with little mobilization. Now, 2.5 years after the surgery, the patient shows remarkable recovery. This result suggests that end-to-end suture is an ideal procedure for nerve traction injury, if the nerve ends can be closed without tension, without excessive flexion of the adjacent joint.
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Affiliation(s)
- Takehiko Takagi
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan.
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42
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Abstract
This report describes the use of articulating external fixation in patients with lower extremity trauma with segmental nerve defects. Four patients who would otherwise require nerve grafting underwent application of an articulated external fixator, allowing optimal positioning for end-to-end, tension-free nerve repair followed by gradual lengthening. After three weeks of immobilization, the fixator was gradually advanced through the arc of the hinge. At an average follow-up of 44 months, motor function testing revealed gastroc-soleus function in all cases with a median motor grade of M4. Sensory function testing with Semmes-Weinstein monofilaments demonstrated protective plantar sensation in all cases with a median monofilament size of 3.84 on the injured limb compared with 3.22 on the contralateral side. This series of patients demonstrates that joint positioning through external fixation may be used safely and effectively to facilitate primary neurorrhaphy and subsequent limb salvage.
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Affiliation(s)
- David S Ruch
- Department o fOrthopaedic Surgery, Wake Forest University Baptist Medcial Center, Winston-Salem, NC 27157, USA.
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43
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Krarup C, Archibald SJ, Madison RD. Factors that influence peripheral nerve regeneration: an electrophysiological study of the monkey median nerve. Ann Neurol 2002; 51:69-81. [PMID: 11782986 DOI: 10.1002/ana.10054] [Citation(s) in RCA: 144] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Regeneration in the peripheral nervous system is often incomplete though it is uncertain which factors, such as the type and extent of the injury or the method or timing of repair, determine the degree of functional recovery. Serial electrophysiological techniques were used to follow recovery from median nerve lesions (n = 46) in nonhuman primates over 3 to 4 years, a time span comparable with such lesions in humans. Nerve gap distances of 5, 20, or 50mm were repaired with nerve grafts or collagen-based nerve guide tubes, and three electrophysiological outcome measures were followed: (1) compound muscle action potentials in the abductor pollicis brevis muscle, (2) the number and size of motor units in reinnervated muscle, and (3) compound sensory action potentials from digital nerve. A statistical model was used to assess the influence of three variables (repair type, nerve gap distance, and time to earliest muscle reinnervation) on the final recovery of the outcome measures. Nerve gap distance and the repair type, individually and concertedly, strongly influenced the time to earliest muscle reinnervation, and only time to reinnervation was significant when all three variables were included as outcome predictors. Thus, nerve gap distance and repair type exert their influence through time to muscle reinnervation. These findings emphasize that factors that control early axonal outgrowth influence the final level of recovery attained years later. They also highlight that a time window exists within which axons must grow through the distal nerve stump in order for recovery after nerve lesions to be optimal. Future work should focus on interventions that may accelerate the growth of axons from the lesion site into the distal nerve stump.
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Affiliation(s)
- Christian Krarup
- Department of Clinical Neurophysiology, National University Hospital (Rigshospitalet), Copenhagen, Denmark.
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44
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45
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Chao RP, Braün SA, Ta KT, Palesty JA, Mine R, Syed SA, Chang DJ, Thomson JG. Early passive mobilization after digital nerve repair and grafting in a fresh cadaver. Plast Reconstr Surg 2001; 108:386-91. [PMID: 11496180 DOI: 10.1097/00006534-200108000-00017] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In the clinical management of combined tendon and nerve injuries, there are competing treatment strategies. Isolated tendon injuries should be rapidly mobilized after repair to prevent adhesion formation, whereas isolated nerve repairs are usually immobilized to prevent disruption and to allow axon regrowth. Recommendations in the published literature for the management of combined tendon and nerve injuries are vague and advise up to 3 weeks of immobilization. The goals of this study were to determine which length of nerve gap resulted in rupture of a repair following postoperative mobilization with the modified Duran protocol and with unrestricted motion and to determine whether nerve grafts are at risk of rupture after mobilization. A total of 100 digital nerves from 10 cadaver hands were tested with the modified Duran and the unsplinted protocols. Each digital nerve on each hand was sequentially resected and repaired at five progressively larger gap lengths after testing with both protocols. The mean nerve gaps at which disruption occurred were significantly different between the splinted (9.7 +/- 0.8 mm, n = 100) and unsplinted (7.3 +/- 1.9 mm, n = 100) protocols (t test, p < 0.001). One hundred percent of repairs remained intact, with up to 5 mm of resection with the modified Duran protocol (n = 100) and with up to 2.5 mm of resection with the unsplinted protocol (n = 100). All nerve grafts remained intact after mobilization within a dorsal-blocking splint (n = 100). Considering mechanical integrity of the nerve repair only, these data suggest that early mobilization with tendon protocols may be considered after a nerve injury to avoid the detrimental tendon sequelae that result from immobilization. The adequacy of functional recovery of mobilized nerves is yet to be determined.
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Affiliation(s)
- R P Chao
- Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT 06520, USA
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46
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Ijkema-Paassen J, Meek MF, Gramsbergen A. Muscle differentiation after sciatic nerve transection and reinnervation in adult rats. Ann Anat 2001; 183:369-77. [PMID: 11508364 DOI: 10.1016/s0940-9602(01)80184-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Reinnervation after peripheral nerve transections generally leads to poor functional recovery. In order to study whether changes in muscles might be a contributing factor in this phenomenon we studied muscle morphology and fibre type distributions after sciatic nerve transection in the rat hind limb. Proximally, before the bifurcation in the tibial and common peroneal nerve, a 12 mm segment of the sciatic nerve was resected, reversed and re-implanted as an autologous nerve graft. After survival periods of 7, 15 and 21 weeks the lateral gastrocnemius, tibialis anterior and soleus muscles were dissected, stained with mATP-ase, and fibre type distributions were studied. In addition, numbers of muscle fibres were counted, and cross sectional areas were calculated. After 7 weeks, cross sectional areas were decreased in all muscles. In the gastrocnemius and tibialis anterior muscles the fibre number remained unaltered but the hypotrophy had been reversed at later ages. The number of muscle fibres in the soleus muscle remained decreased over the entire period of observation. The percentages of type II fibres in the gastrocnemius and tibialis anterior muscles were decreased at 7 and 15 weeks but these again approached normal values at 21 weeks. The type I fibres, however, remained arranged in groups. In the soleus muscle a large increase in the percentage of type II muscle fibres was observed and this remained until 21 weeks. We conclude that a non-selective reinnervation and later readjustments by regression of polyneural innervation may in part explain the changes in distributions of various fibre types.
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47
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Acuña García M, Gil Carcedo García LM, Alvarez Iscar N, Redondo LM, Serrat Soto A, Rodríguez Toves LA, Vaquero Puerta C. [Repair of facial nerve gaps with cryopreserved allografts in rats immunosuppressed with cyclosporin A]. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2001; 52:320-6. [PMID: 11526628 DOI: 10.1016/s0001-6519(01)78214-3] [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: 11/22/2022]
Abstract
UNLABELLED The aim of this study is to assess the feasibility of peripheral nerve allografts pretreated utilizing cold storage and cyclosporin A to improve the facial nerve regeneration in Wistar rat. Three groups were designed: Normal Wistar rats. 4 millimeters nerve gaps repaired with cryopreserved nerve allografts. 4 millimeters nerve gaps repaired with cryopreserved nerve grafts and treated with cyclosporin A. At 16 weeks post-engraftment the animals were evaluated: Facial palsy grading system. Electrophysiologic latency. Axonal counting. Nervous fiber area immediately distal to the graft. The facial function of the experimental groups was similar to the control rats while the latency and morphometric parameters was poor than the normal rats. CONCLUSIONS 1. Cryopreserved nerve allografts in facial nerve repair in rats are useful in the aquisition of a facial functional nerve recovery as much in immunosuppressed animal as not. 2. Cryopreservation of nerve allografts results a good method of storage of nerve grafts. 3. Cyclosporin A immunosuppression improved not much the grading facial palsy in this model but the electrophysiologic and morphometry is significantly better.
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Affiliation(s)
- M Acuña García
- Cátedra de ORL, Facultad de Medicina, Universidad de Valladolid
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48
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Ustün ME, Oğün TC, Büyükmumcu M, Salbacak A. Selective restoration of motor function in the ulnar nerve by transfer of the anterior interosseous nerve. An anatomical feasibility study. J Bone Joint Surg Am 2001; 83:549-52. [PMID: 11315783 DOI: 10.2106/00004623-200104000-00009] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal ulnar-nerve lesions have an unfavorable prognosis. The goal of the present study was to evaluate the feasibility of selective restoration of motor function of the ulnar nerve by the transfer of the anterior interosseous nerve or one of its branches to the motor branch of the ulnar nerve. METHODS Ten cadaveric arms were used in the present study. The ulnar nerve and its motor and sensory branches as well as the anterior interosseous nerve and its branches were dissected. The widths of the motor branch of the ulnar nerve and the anterior interosseous nerve and its motor branches as well as the relevant distances from the points of divergence were measured. The axons were counted, and the distances from the end of the main anterior interosseous nerve, its motor branches, and the motor branch of the ulnar nerve to the level of the dorsal sensory branch of the ulnar nerve were measured. RESULTS Our results indicate that the length, width, and number of axons of the branch of the anterior interosseous nerve to the pronator quadratus make it suitable for transfer to the motor branch of the ulnar nerve. The use of the main anterior interosseous nerve or its motor branches to the flexor pollicis longus and the flexor digitorum profundus is less feasible because of the need to graft a long segment and the longer distance from the level of transfer to the motor end points. CONCLUSIONS The findings of the present study confirm the feasibility of motor-nerve transfer for reconstruction after an injury of the ulnar nerve. Nerve-grafting would be needed for injuries distal to the level of the dorsal sensory branch of the ulnar nerve.
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Affiliation(s)
- M E Ustün
- Selçuk University Medical School, Konya, Turkey
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49
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Abstract
Peripheral nerve injuries are common, and there is no easily available formula for successful treatment. Incomplete injuries are most frequent. Seddon classified nerve injuries into three categories: neurapraxia, axonotmesis, and neurotmesis. After complete axonal transection, the neuron undergoes a number of degenerative processes, followed by attempts at regeneration. A distal growth cone seeks out connections with the degenerated distal fiber. The current surgical standard is epineurial repair with nylon suture. To span gaps that primary repair cannot bridge without excessive tension, nerve-cable interfascicular auto-grafts are employed. Unfortunately, results of nerve repair to date have been no better than fair, with only 50% of patients regaining useful function. There is much ongoing research regarding pharmacologic agents, immune system modulators, enhancing factors, and entubulation chambers. Clinically applicable developments from these investigations will continue to improve the results of treatment of nerve injuries.
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Affiliation(s)
- S K Lee
- United States Air Force, Section of Orthopaedic Surgery, Walson Air Force Hospital, Fort Dix, NJ, USA
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50
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Maeda T, Hori S, Sasaki S, Maruo S. Effects of tension at the site of coaptation on recovery of sciatic nerve function after neurorrhaphy: evaluation by walking-track measurement, electrophysiology, histomorphometry, and electron probe X-ray microanalysis. Microsurgery 2000; 19:200-7. [PMID: 10336250 DOI: 10.1002/(sici)1098-2752(1999)19:4<200::aid-micr7>3.0.co;2-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The effects of tension at the site of coaptation on recovery of sciatic nerve function after neurorrhaphy were studied by evaluating walking-track measurements, nerve conduction velocity measurements, histomorphometry, and electron probe X-ray microanalysis. Forty adult male Lewis rats underwent right sciatic nerve (SN) transection followed by one of four different nerve repair procedures (N = 10 rats per group). In Group 1, the gap was repaired by end-to-end epineural coaptation. In Group 2, a 5-mm segment of SN was resected, and the defect was repaired under high tension by epineural neurorrhaphy. In Group 3, a 5-mm segment of SN was resected, and the defect was repaired with a 5-mm interposition nerve graft. In Group 4, a 5-mm segment of SN was resected. Then, to lessen the tension that follows neurorrhaphy, an anchoring suture was added. Finally, end-to-end coaptation was performed. Walking-track analysis showed better functional recovery in Group 1 than in Group 2, and better recovery in Group 3 than in Group 2. Group 4 showed a tendency toward better recovery comparing with Group 2. Electron probe X-ray microanalysis revealed higher Na, Cl, and K peaks in axoplasm accompanied by increase in the endoneural fluid pressure (EFP) in Group 2 than those of Group 1. This higher level of Na, Cl and K may be due to impairment of axonal sodium and potassium transport mechanism in Group 2. Increase in EFP may affect nerve regeneration.
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Affiliation(s)
- T Maeda
- Department of Physiology, Hyogo College of Medicine, Nishinomiya, Japan.
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