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Doherty C, Brown E, Berger M, Seal A, Tang D, Chandler R, Bristol S. Contemporary Approaches to Peripheral Nerve Surgery. Plast Surg (Oakv) 2024; 32:516-527. [PMID: 39104941 PMCID: PMC11298148 DOI: 10.1177/22925503221120571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 08/07/2024] Open
Abstract
"State of the Art" Learning Objectives: This manuscript serves to provide the reader with a general overview of the contemporary approaches to peripheral nerve reconstruction as the field has undergone considerable advancement over the last 3 decades. The learning objectives are as follows: To provide the reader with a brief history of peripheral nerve surgery and some of the landmark developments that allow for current peripheral nerve care practices.To outline the considerations and management options for the care of patients with brachial plexopathy, spinal cord injury, and lower extremity peripheral nerve injury.Highlight contemporary surgical techniques to address terminal neuroma and phantom limb pain.Review progressive and future procedures in peripheral nerve care, such as supercharge end-to-side nerve transfers.Discuss rehabilitation techniques for peripheral nerve care.
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Affiliation(s)
- Christopher Doherty
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- ICORD, International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
| | - Erin Brown
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- ICORD, International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
| | - Michael Berger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- ICORD, International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
| | - Alexander Seal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Tang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rowan Chandler
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean Bristol
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Abaskhron M, Ezzat M, Boulis AG, Safoury YE. Supercharged end-to-side anterior interosseous nerve transfer to restore intrinsic function in high ulnar nerve injury: a prospective cohort study. BMC Musculoskelet Disord 2024; 25:566. [PMID: 39033290 PMCID: PMC11264796 DOI: 10.1186/s12891-024-07650-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/01/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND High ulnar nerve injuries is known to have unfavorable motor outcomes compared to other peripheral nerve injuries in the upper extremity. Functional muscle recovery after peripheral nerve injury depends on the time to motor end plate reinnervation and the number of motor axons that successfully reach the target muscle. The purpose of this study is to assess the functional recovery, and complications following performing supercharge end-to-side (SETS) anastomosis for proximal ulnar nerve injuries. Our study focuses on the role of SETS in the recovery process of high ulnar nerve injury. PATIENT AND METHODS This study is a prospective, single-arm, open-label, case series. The original proximal nerve pathology was dealt with according to the cause of injury, then SETS was performed distally. The follow-up period was 18 months. We compared the neurological findings before and after the procedure. A new test was used to show the effect of SETS on recovery by performing a Lidocaine proximal ulnar nerve block test. RESULTS Recovery of the motor function of the ulnar nerve was evident in 33 (86.8%) patients. The mean time to intrinsic muscle recovery was 6.85 months ± 1.3, only 11.14% of patients restored protective sensation to the palm and finger and 86.8% showed sensory level at the wrist level at the end of the follow-up period. Lidocaine block test was performed on 35 recovered patients and showed no change in intrinsic hand function in 31 patients. CONCLUSION SETS exhibit a remarkable role in the treatment of high ulnar nerve damage. SETS transfer can act as a nerve transfer that can supply intrinsic muscles by its fibers and allows for proximal nerve regeneration. We believe that this technique improves recovery of hand motor function and allows recovery of sensory fibers when combined with treating the proximal lesion. TRIAL REGISTRATION Approved by Research Ethics Committee of Faculty of Medicine- Cairo University on 01/09/2021 with code number: MD-215-2021.
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Affiliation(s)
- Mina Abaskhron
- Department of Orthopaedic and Traumatology, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Mostafa Ezzat
- Department of Orthopaedic and Traumatology, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Andrew Gamal Boulis
- Department of Orthopaedic and Traumatology, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Yasser El Safoury
- Department of Orthopaedic and Traumatology, Kasr Al Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
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Robinson LR, Dengler J. Understanding the role of the lower motor neuron in spinal cord injury and its impact on electrodiagnostic assessment. Muscle Nerve 2024; 70:6-8. [PMID: 38712656 DOI: 10.1002/mus.28108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/08/2024]
Affiliation(s)
- Lawrence R Robinson
- Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Jana Dengler
- Division of Plastic, Reconstructive and Aesthetic Surgery, University of Toronto, Toronto, Ontario, Canada
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Bateman EA, Pripotnev S, Larocerie-Salgado J, Ross DC, Miller TA. Assessment, management, and rehabilitation of traumatic peripheral nerve injuries for non-surgeons. Muscle Nerve 2024. [PMID: 39030747 DOI: 10.1002/mus.28185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/28/2024] [Accepted: 06/02/2024] [Indexed: 07/22/2024]
Abstract
Electrodiagnostic evaluation is often requested for persons with peripheral nerve injuries and plays an important role in their diagnosis, prognosis, and management. Peripheral nerve injuries are common and can have devastating effects on patients' physical, psychological, and socioeconomic well-being; alongside surgeons, electrodiagnostic medicine specialists serve a central function in ensuring patients receive optimal treatment for these injuries. Surgical intervention-nerve grafting, nerve transfers, and tendon transfers-often plays a critical role in the management of these injuries and the restoration of patients' function. Increasingly, nerve transfers are becoming the standard of care for some types of peripheral nerve injury due to two significant advantages: first, they shorten the time to reinnervation of denervated muscles; and second, they confer greater specificity in directing motor and sensory axons toward their respective targets. As the indications for, and use of, nerve transfers expand, so too does the role of the electrodiagnostic medicine specialist in establishing or confirming the diagnosis, determining the injury's prognosis, recommending treatment, aiding in surgical planning, and supporting rehabilitation. Having a working knowledge of nerve and/or tendon transfer options allows the electrodiagnostic medicine specialist to not only arrive at the diagnosis and prognosticate, but also to clarify which nerves and/or muscles might be suitable donors, such as confirming whether the branch to supinator could be a nerve transfer donor to restore distal posterior interosseous nerve function. Moreover, post-operative testing can determine if nerve transfer reinnervation is occurring and progress patients' rehabilitation and/or direct surgeons to consider tendon transfers.
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Affiliation(s)
- Emma A Bateman
- Parkwood Institute, St Joseph's Health Care London, London, Canada
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Stahs Pripotnev
- Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | | | - Douglas C Ross
- Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Thomas A Miller
- Parkwood Institute, St Joseph's Health Care London, London, Canada
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Canada
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Wilcox M, Brown H, Johnson K, Sinisi M, Quick TJ. An assessment of co-contraction in reinnervated muscle. Regen Med 2024; 19:161-170. [PMID: 37955237 DOI: 10.2217/rme-2023-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
Aim: To investigate co-contraction in reinnervated elbow flexor muscles following a nerve transfer. Materials & methods: 12 brachial plexus injury patients who received a nerve transfer to reanimate elbow flexion were included in this study. Surface electromyography (EMG) recordings were used to quantify co-contraction during sustained and repeated isometric contractions of reinnervated and contralateral uninjured elbow flexor muscles. Reuslts: For the first time, this study reveals reinnervated muscles demonstrated a trend toward higher co-contraction ratios when compared with uninjured muscle and this is correlated with an earlier onset of muscle fatigability. Conclusion: Measurements of co-contraction should be considered within muscular function assessments to help drive improvements in motor recovery therapies.
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Affiliation(s)
- Matthew Wilcox
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, London, HA7 4LP, UK
- University College London Centre for Nerve Engineering, London, WC1E 6BT, UK
- Department of Pharmacology, University College London, School of Pharmacy, London, WC1N 1AX, UK
| | - Hazel Brown
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, London, HA7 4LP, UK
- University College London Centre for Nerve Engineering, London, WC1E 6BT, UK
| | - Kathryn Johnson
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, London, HA7 4LP, UK
| | - Marco Sinisi
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, London, HA7 4LP, UK
| | - Tom J Quick
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, London, HA7 4LP, UK
- University College London Centre for Nerve Engineering, London, WC1E 6BT, UK
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O'Sullivan J, Jeffrey J, Miller C, Power D. Rehabilitation Following a Triceps Branch to Axillary Motor Nerve Transfer-A Pragmatic Therapy Guide. Tech Hand Up Extrem Surg 2024; 28:2-8. [PMID: 37622599 DOI: 10.1097/bth.0000000000000450] [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: 08/26/2023]
Abstract
Peripheral motor nerve transfer surgery is a technique that may be used to restore motor function to paralyzed muscles. Motor nerve transfer involves harvesting an expendable motor nerve branch, and transfer to the motor branch of the denervated target muscle, using microsurgical coaptation. To date, a standardized rehabilitation protocol does not exist. The 6 stages of rehabilitation after motor nerve transfer surgery were outlined by colleagues in the Birmingham Peripheral Nerve Injury service in 2019. This article aims to provide a practical therapy perspective on the rehabilitation stages of motor nerve transfer surgery outlined in that paper, focusing on the radial to axillary nerve transfer. Timeframes for each stage along with exercise prescription and rationale are provided.
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Affiliation(s)
| | | | | | - Dominic Power
- Birmingham Peripheral Nerve Injury Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, United Kingdom
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Kahn LC, Stonner MM, Dy CJ. Key Considerations for Nerve Transfer Rehabilitation After Surgical Reconstruction for Brachial Plexus and Peripheral Nerve Injuries. J Hand Surg Am 2024; 49:160-168. [PMID: 37999701 DOI: 10.1016/j.jhsa.2023.09.016] [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: 04/05/2023] [Revised: 08/30/2023] [Accepted: 09/19/2023] [Indexed: 11/25/2023]
Abstract
Nerve transfer surgery is commonly used to treat patients with brachial plexus injuries. However, guidelines on postoperative rehabilitation are not clearly established. Nerve transfers require the patient to relearn how to recruit newly innervated muscle(s), which may not occur naturally or intuitively. Supervised therapy is a valuable resource to guide patients through their lengthy recovery (often >12 months) because target muscle strength is both obtained and functionally used in daily life. This article highlights 10 key principles that provide the foundation for rehabilitation following nerve transfer surgery after a brachial plexus injury. Due to the shortcomings of the current evidence base for nerve transfer rehabilitation, we have included our anecdotal experience to augment the existing literature. It is important to have a collaborative surgeon-therapist relationship to communicate regarding operative details, expected timelines for reinnervation, patient needs, and realistic expectations. We provide examples of how to tailor the exercise program to synergistically recruit both the donor and target muscle action, including how to appropriately advance exercises based on the current level of nerve return. We also discuss the role that fatigue plays in denervated muscle and how fatigue may affect the exercise demands placed on the target muscle during specific stages of recovery.
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Affiliation(s)
- Lorna C Kahn
- Milliken Hand Rehabilitation Center, Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO
| | - Macyn M Stonner
- Milliken Hand Rehabilitation Center, Program in Occupational Therapy, Washington University School of Medicine, St. Louis, MO
| | - Christopher J Dy
- Division of Hand and Microsurgery, Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO.
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Thorkildsen RD, Kleggetveit IP, Thu F, Madsen LM, Bolstad BJ, Røkkum M. Supercharging of the ulnar nerve: clinical and neurophysiological assessment at 2 years for nine proximal injuries. J Hand Surg Eur Vol 2024:17531934231226174. [PMID: 38235708 DOI: 10.1177/17531934231226174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
LEVEL OF EVIDENCE II.
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Affiliation(s)
- Rasmus Dehli Thorkildsen
- Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Inge Petter Kleggetveit
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Frode Thu
- Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Lise Maurstad Madsen
- Section for Orthopaedic Rehabilitation, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørg Johanna Bolstad
- Section for Orthopaedic Rehabilitation, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Magne Røkkum
- Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
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9
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Wang R, Zhang S, Zhang J, Tong Q, Ye X, Wang K, Li J. Electromyographic biofeedback therapy for improving limb function after stroke: A systematic review and meta-analysis. PLoS One 2024; 19:e0289572. [PMID: 38206927 PMCID: PMC10783731 DOI: 10.1371/journal.pone.0289572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/21/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Upper and lower limb impairment is common after stroke. Electromyographic biofeedback therapy is a non-invasive treatment, and its effectiveness in functional rehabilitation of the limb after stroke still remains uncertain. OBJECTIVE The objective of this study was to evaluate whether electromyographic biofeedback can improve upper and lower limb dysfunction in stroke patients. METHODS PubMed, Embase, Cochrane Library, and Physiotherapy Evidence Database (PEDro) were searched from inception to 1st May 2022. Inclusion criteria were randomized controlled clinical trials of electromyographic biofeedback therapy interventions reporting changes in upper and lower limb function in post-stroke patients. Data were extracted by two independent reviewers and pooled in random-effects models using Review manager (RevMan) software. RESULTS Our analyses included 10 studies enrolling a total of 303 participants. Electromyographic biofeedback therapy can effectively improve limb function after stroke (standardized mean difference [SMD], 0.44; 95% confidence interval [CI], 0.12-0.77; P = 0.008) and in subgroup analyses, the effect sizes of short-term effect (SMD, 0.33; 95% CI, 0.02-0.64; P = 0.04) was significant, but the long-term was not (SMD, 0.61; 95% CI, -0.11-1.33; P = 0.10). In addition, Electromyographic biofeedback therapy can improve the active range of motion of shoulder (SMD, 1.49; 95% CI, 2.22; P<0.0001) and wrist joints (SMD, 0.77; 95% CI, 0.13-1.42; P = 0.02) after stroke. CONCLUSION In this meta-analysis, electromyographic biofeedback therapy intervention can improve upper and lower limb function in patients with stroke. Short-term (less than one month) improvement after electromyographic biofeedback therapy was supported, while evidence for long-term (more than one month) benefits was lacking. Range of motion in the glenohumeral and wrist joints were improved. Stronger evidence for individualized parameters, such as optimal treatment parameters and intervention period, is needed in the future. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/display_record.php?recordID=267596], identifier [CRD42022354363].
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Affiliation(s)
- Rui Wang
- Department of The Second Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Shuangshuang Zhang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jie Zhang
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qifeng Tong
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
- College of Rehabilitation, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiangming Ye
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Kai Wang
- Department of Neurology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Juebao Li
- Center for Rehabilitation Medicine, Rehabilitation & Sports Medicine Research Institute of Zhejiang Province, Department of Rehabilitation Medicine, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
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10
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Wang S, Zhou W, Zhou Q, Yin Y. Comparison of nerve versus tendon transfer for radial nerve palsy. Clin Neurol Neurosurg 2024; 236:108077. [PMID: 38091705 DOI: 10.1016/j.clineuro.2023.108077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE This study aims to investigate the choice of intervention time and operation mode between nerve and tendon transfer for the treatment of radial nerve palsy (RNP). METHODS 46 RNP patients underwent nerve transfer (n = 22) and tendon transfer (n = 24). The intraoperative blood loss, main incision length, operation duration, and length of hospital stay and follow-up period of patients in these two groups were recorded and compared. The range of motion (ROM) of the elbow, wrist, fingers, and thumb, the hand grip and pinch strength, the Disabilities of Arm, Shoulder, and Hand (DASH) and the 36-Item Short Form Health Survey (SF-36) scores were measured and compared preoperatively and postoperatively between the two groups. RESULTS The ROM of thumb and the hand grip strength of patients in the nerve transfer group were greater than that in the tendon transfer (P < 0.05). Both of the two groups indicated significant improvements in the ROM of elbow, wrist, finger, thumb and the hand grip and pinch strength (P < 0.05) postoperatively. The DASH scores decreased significantly at 6 months (P < 0.05) and 12 months (P < 0.05) after surgery in both groups, while the postoperative SF-36 scores significantly increased (P < 0.05). There was no significant difference in postoperative DASH and SF-36 scores between the two groups (P > 0.05). CONCLUSION In summary, both nerve and tendon transfer techniques are effective treatments for RNP. Nerve transfer is particularly advantageous for early RNP, while tendon transfer is suitable for patients with radial nerve injury more than one year.
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Affiliation(s)
- Shengtao Wang
- Department of Orthopedics, Pidu District People's Hospital, the Third Affiliated Hospital of Chengdu Medical College, Chengdu 611730, PR China
| | - Wei Zhou
- Department of Orthopedics, Pidu District People's Hospital, the Third Affiliated Hospital of Chengdu Medical College, Chengdu 611730, PR China
| | - Qingsong Zhou
- Department of Orthopedics, Pidu District People's Hospital, the Third Affiliated Hospital of Chengdu Medical College, Chengdu 611730, PR China
| | - Yong Yin
- Department of Orthopedics, Pidu District People's Hospital, the Third Affiliated Hospital of Chengdu Medical College, Chengdu 611730, PR China.
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Bateman EA, Larocerie-Salgado J, Ross DC, Miller TA, Pripotnev S. Assessment, patient selection, and rehabilitation of nerve transfers. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1267433. [PMID: 38058570 PMCID: PMC10696649 DOI: 10.3389/fresc.2023.1267433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
Peripheral nerve injuries are common and can have a devastating effect on physical, psychological, and socioeconomic wellbeing. Peripheral nerve transfers have become the standard of care for many types of peripheral nerve injury due to their superior outcomes relative to conventional techniques. As the indications for, and use of, nerve transfers expand, the importance of pre-operative assessment and post-operative optimization increases. There are two principal advantages of nerve transfers: (1) their ability to shorten the time to reinnervation of muscles undergoing denervation because of peripheral nerve injury; and (2) their specificity in ensuring proximal motor and sensory axons are directed towards appropriate motor and sensory targets. Compared to conventional nerve grafting, nerve transfers offer opportunities to reinnervate muscles affected by cervical spinal cord injury and to augment natural reinnervation potential for very proximal injuries. This article provides a narrative review of the current scientific knowledge and clinical understanding of nerve transfers including peripheral nerve injury assessment and pre- and post-operative electrodiagnostic testing, adjuvant therapies, and post-operative rehabilitation for optimizing nerve transfer outcomes.
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Affiliation(s)
- Emma A. Bateman
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | | | - Douglas C. Ross
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Thomas A. Miller
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | - Stahs Pripotnev
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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12
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Fasce I, Fiaschi P, Bianconi A, Sacco C, Staffa G, Capone C. Long-term functional recovery in C5-C6 avulsions treated with distal nerve transfers. Neurol Res 2023; 45:867-873. [PMID: 34193028 DOI: 10.1080/01616412.2021.1942410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In patients suffering from traction lesions of the brachial plexus, complete C5 and/or C6 root avulsion patients with C7 root preservation are relatively uncommon occurrences, but represent excellent candidates for surgical treatment, with satisfactory results. Shoulder abduction and extra-rotation, elbow flexion and forearm supination are lost functions restorable with surgical treatment. METHODS This single-center, prospective observational study involved a series of 27 young adults with C5 and/or C6 root complete avulsion and C7 preservation, which underwent surgical repair with double or triple nerve transfer. RESULTS Patients recovered a useful elbow flexion. Electromyographic and clinical signs of biceps reinnervation were observed in each UN-MC nerve transfer. The abduction strength recovery was M5 in 10 patients, M4 in 14 patients and M3 in 3 patients. The external rotation strength recovery was M5 in 4 patients, M4 in 18 patients, M3 in 3 patients and M2 in 2 patients. The elbow flection strength was M5 in 5 patients, M4 in 15 patients and M3 in 7 patients. Elbow extension was preserved in all cases. CONCLUSIONS The concept of 'peripheral rewiring procedures' represents an advance in the repair of the peripheral nerve injuries. Triple nerve transfer can be nowadays considered a standard treatment for isolated C5-C6 avulsions. We report our experience with the second-biggest casuistry in the literature on patients treated with this technique. We consider our outcome concerning functional recovery to be satisfying and comparable to data reported in the literature.
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Affiliation(s)
- Irene Fasce
- Department of Neurosurgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Università di Genova, Genova, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Università di Genova, Genova, Italy
| | - Andrea Bianconi
- Department of Neurosurgery, Università Degli Studi dI Torino, Torino, Italy
| | - Carlo Sacco
- Department of Peripheral Nerve Surgery, Ospedale Civile Degli Infermi, Faenza, Italy
| | - Guido Staffa
- Department of Peripheral Nerve Surgery, Ospedale Civile Degli Infermi, Faenza, Italy
| | - Crescenzo Capone
- Department of Peripheral Nerve Surgery, Ospedale Civile Degli Infermi, Faenza, Italy
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Li H, Chen J, Wang J, Zhang T, Chen Z. Review of rehabilitation protocols for brachial plexus injury. Front Neurol 2023; 14:1084223. [PMID: 37139070 PMCID: PMC10150106 DOI: 10.3389/fneur.2023.1084223] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Brachial plexus injury (BPI) is one of the most serious peripheral nerve injuries, resulting in severe and persistent impairments of the upper limb and disability in adults and children alike. With the relatively mature early diagnosis and surgical technique of brachial plexus injury, the demand for rehabilitation treatment after brachial plexus injury is gradually increasing. Rehabilitation intervention can be beneficial to some extent during all stages of recovery, including the spontaneous recovery period, the postoperative period, and the sequelae period. However, due to the complex composition of the brachial plexus, location of injury, and the different causes, the treatment varies. A clear rehabilitation process has not been developed yet. Rehabilitation therapy that has been widely studied focusing on exercise therapy, sensory training, neuroelectromagnetic stimulation, neurotrophic factors, acupuncture and massage therapy, etc., while interventions like hydrotherapy, phototherapy, and neural stem cell therapy are less studied. In addition, rehabilitation methods in some special condition and group often neglected, such as postoperative edema, pain, and neonates. The purpose of this article is to explore the potential contributions of various methods to brachial plexus injury rehabilitation and to provide a concise overview of the interventions that have been shown to be beneficial. The key contribution of this article is to form relatively clear rehabilitation processes based on different periods and populations, which provides an important reference for the treatment of brachial plexus injuries.
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Patterson JMM, Russo SA, El-Haj M, Novak CB, Mackinnon SE. Radial Nerve Palsy: Nerve Transfer Versus Tendon Transfer to Restore Function. Hand (N Y) 2022; 17:1082-1089. [PMID: 33530787 PMCID: PMC9608274 DOI: 10.1177/1558944720988126] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radial nerve injuries cause profound disability, and a variety of reconstruction options exist. This study aimed to compare outcomes of tendon transfers versus nerve transfers for the management of isolated radial nerve injuries. METHODS A retrospective chart review of 30 patients with isolated radial nerve injuries treated with tendon transfers and 16 patients managed with nerve transfers was performed. Fifteen of the 16 patients treated with nerve transfer had concomitant pronator teres to extensor carpi radialis brevis tendon transfer for wrist extension. Preoperative and postoperative strength data, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and quality-of-life (QOL) scores were compared before and after surgery and compared between groups. RESULTS For the nerve transfer group, patients were significantly younger, time from injury to surgery was significantly shorter, and follow-up time was significantly longer. Both groups demonstrated significant improvements in grip and pinch strength after surgery. Postoperative grip strength was significantly higher in the nerve transfer group. Postoperative pinch strength did not differ between groups. Similarly, both groups showed an improvement in DASH and QOL scores after surgery with no significant differences between the 2 groups. CONCLUSIONS The nerve transfer group demonstrated greater grip strength, but both groups had improved pain, function, and satisfaction postoperatively. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. Both tendon transfers and nerve transfers are good options for patients with radial nerve palsy.
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Affiliation(s)
| | | | - Madi El-Haj
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
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15
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Javeed S, Dibble CF, Greenberg JK, Zhang JK, Khalifeh JM, Park Y, Wilson TJ, Zager EL, Faraji AH, Mahan MA, Yang LJ, Midha R, Juknis N, Ray WZ. Upper Limb Nerve Transfer Surgery in Patients With Tetraplegia. JAMA Netw Open 2022; 5:e2243890. [PMID: 36441549 PMCID: PMC9706368 DOI: 10.1001/jamanetworkopen.2022.43890] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Cervical spinal cord injury (SCI) causes devastating loss of upper extremity function and independence. Nerve transfers are a promising approach to reanimate upper limbs; however, there remains a paucity of high-quality evidence supporting a clinical benefit for patients with tetraplegia. OBJECTIVE To evaluate the clinical utility of nerve transfers for reanimation of upper limb function in tetraplegia. DESIGN, SETTING, AND PARTICIPANTS In this prospective case series, adults with cervical SCI and upper extremity paralysis whose recovery plateaued were enrolled between September 1, 2015, and January 31, 2019. Data analysis was performed from August 2021 to February 2022. INTERVENTIONS Nerve transfers to reanimate upper extremity motor function with target reinnervation of elbow extension and hand grasp, pinch, and/or release. MAIN OUTCOMES AND MEASURES The primary outcome was motor strength measured by Medical Research Council (MRC) grades 0 to 5. Secondary outcomes included Sollerman Hand Function Test (SHFT); Michigan Hand Outcome Questionnaire (MHQ); Disabilities of Arm, Shoulder, and Hand (DASH); and 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) scores. Outcomes were assessed up to 48 months postoperatively. RESULTS Twenty-two patients with tetraplegia (median age, 36 years [range, 18-76 years]; 21 male [95%]) underwent 60 nerve transfers on 35 upper limbs at a median time of 21 months (range, 6-142 months) after SCI. At final follow-up, upper limb motor strength improved significantly: median MRC grades were 3 (IQR, 2.5-4; P = .01) for triceps, with 70% of upper limbs gaining an MRC grade of 3 or higher for elbow extension; 4 (IQR, 2-4; P < .001) for finger extensors, with 79% of hands gaining an MRC grade of 3 or higher for finger extension; and 2 (IQR, 1-3; P < .001) for finger flexors, with 52% of hands gaining an MRC grade of 3 or higher for finger flexion. The secondary outcomes of SHFT, MHQ, DASH, and SF36-PCS scores improved beyond the established minimal clinically important difference. Both early (<12 months) and delayed (≥12 months) nerve transfers after SCI achieved comparable motor outcomes. Continual improvement in motor strength was observed in the finger flexors and extensors across the entire duration of follow-up. CONCLUSIONS AND RELEVANCE In this prospective case series, nerve transfer surgery was associated with improvement of upper limb motor strength and functional independence in patients with tetraplegia. Nerve transfer is a promising intervention feasible in both subacute and chronic SCI.
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Affiliation(s)
- Saad Javeed
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | | | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Justin K. Zhang
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Jawad M. Khalifeh
- Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Yikyung Park
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Thomas J. Wilson
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Eric L. Zager
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Amir H. Faraji
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas
| | - Mark A. Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, The University of Utah, Salt Lake City
| | - Lynda J. Yang
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor
| | - Rajiv Midha
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Neringa Juknis
- Physical Medicine and Rehabilitation, Washington University, St Louis, Missouri
| | - Wilson Z. Ray
- Department of Neurological Surgery, Washington University, St Louis, Missouri
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Tsai YJ, Hsiao CK, Su FC, Tu YK. Clinical Assessment of Functional Recovery Following Nerve Transfer for Traumatic Brachial Plexus Injuries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12416. [PMID: 36231711 PMCID: PMC9564654 DOI: 10.3390/ijerph191912416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/15/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
Surgical reconstruction and postoperative rehabilitation are both important for restoring function in patients with traumatic brachial plexus injuries (BPIs). The current study aimed to understand variations in recovery progression among patients with different injury levels after receiving the nerve transfer methods. A total of 26 patients with BPIs participated in a rehabilitation training program over 6 months after nerve reconstruction. The differences between the first and second evaluations and between C5-C6 and C5-C7 BPIs were compared. Results showed significant improvements in elbow flexion range (p = 0.001), British Medical Research Council's score of shoulder flexion (p = 0.046), shoulder abduction (p = 0.013), shoulder external rotation (p = 0.020), quantitative muscle strength, and grip strength at the second evaluation for both groups. C5-C6 BPIs patients showed a larger shoulder flexion range (p = 0.022) and greater strength of the shoulder rotator (p = 0.004), elbow flexor (p = 0.028), elbow extensor (p = 0.041), wrist extensor (p = 0.001), and grip force (p = 0.045) than C5-C7 BPIs patients at the second evaluation. Our results indicated different improvements among patients according to injury levels, with quantitative values assisting in establishing goals for interventions.
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Affiliation(s)
- Yi-Jung Tsai
- Department of Medical Research, E-Da Hospital, Kaohsiung 82445, Taiwan
- Medical College, I-Shou University, Kaohsiung 82445, Taiwan
| | - Chih-Kun Hsiao
- Department of Medical Research, E-Da Hospital, Kaohsiung 82445, Taiwan
| | - Fong-Chin Su
- Department of Biomedical Engineering, National Cheng Kung University, Tainan 70101, Taiwan
- Medical Device Innovation Center, National Cheng Kung University, Tainan 70101, Taiwan
| | - Yuan-Kun Tu
- Medical College, I-Shou University, Kaohsiung 82445, Taiwan
- Department of Orthopedics, E-Da Hospital, Kaohsiung 82445, Taiwan
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17
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Surface Electromyography-Driven Therapeutic Gaming for Rehabilitation of Upper Extremity Weakness: A Pilot Study. Plast Reconstr Surg 2022; 150:125-131. [PMID: 35544314 DOI: 10.1097/prs.0000000000009208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
SUMMARY In patients with severe upper extremity weakness that may result from peripheral nerve injuries, stroke, and spinal cord injuries, standard therapy in the earliest stages of recovery consists primarily of passive rather than active exercises. Adherence to prescribed therapy may be poor, which may contribute to suboptimal functional outcomes. The authors have developed and integrated a custom surface electromyography device with a video game to create an interactive, biofeedback-based therapeutic gaming platform. Sensitivity of the authors' custom surface electromyography device was evaluated with simultaneous needle electromyography recordings. Testing of this therapeutic gaming platform was conducted with a single 30-minute gameplay session in 19 patients with a history of peripheral nerve injury, stroke, spinal cord injury, and direct upper extremity trauma, including 11 patients who had undergone nerve and/or tendon transfers. The device was highly sensitive in detecting low levels of voluntary muscle activation and was used with 10 distinct muscles of the arm, forearm, and hand. Nerve and tendon transfer patients successfully activated the donor nerve/muscle and elicited the desired movement to engage in gameplay. On surveys of acceptability and usability, patients felt the system was enjoyable, motivating, fun, and easy to use, and their hand therapists expressed similar enthusiasm. Surface electromyography-based therapeutic gaming is a promising approach to rehabilitation that warrants further development and investigation to examine its potential efficacy, not only for building muscle strength and endurance but also for facilitating motor relearning after nerve and tendon transfer surgical procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Brito S, White J, Hill B, Thomacos N. Effective long-term management of brachial plexus injury following surgery: What is needed from hand therapists' perspectives. J Hand Ther 2022; 35:267-274. [PMID: 35246366 DOI: 10.1016/j.jht.2022.01.006] [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: 10/24/2020] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Traumatic, brachial plexus injuries (BPI) result represent a significant cost to the individual and society. Recovery involves multiple surgeries, takes years, and often results in permanent physical dysfunction. While the last couple of decades have seen advancements in surgical management, the BPI rehabilitation literature has not kept pace with these developments. PURPOSE We aim to explore the experience of public and privately employed hand therapists' in delivering effective long-term rehabilitation services to inviduals with BPI in Australia. METHODS An interpretative qualitative study. Two focus groups were conducted with Australian hand therapists' (n = 10). Data were analyzed using an inductive thematic approach. RESULTS Three key themes were generated from the data. The first theme 'Falling through the gaps: overlooked components of therapy for BPI' captures participants' thoughts on postinjury health care and rehabilitation services. The second 'Developing a therapeutic alliance: underpinned by time and trust' relates to the relationship building challenges and opportunities following trauma that will withstand the long-term recovery of individuals following BPI. The last theme, 'Factors required for professional development: knowledge and support,' considers the variation seen with these clients in relation to therapy needs and outcomes. CONCLUSIONS The findings of this study highlight the need to better equip hand therapists' skills and knowledge in responding to pain and psychological management post BPI. Our results reinforce the benefit of interdisciplinary models of care in the management of individuals with BPI.
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Affiliation(s)
- Sara Brito
- Occupational Therapy Department, Federation University, Churchill, Victoria, Australia; Department of Occupational Therapy, Monash University, Frankston, Victoria, Australia.
| | - Jennifer White
- Department of Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Bridget Hill
- Epworth Monash Rehabilitation Medicine Unit, Epworth Hospital, Richmond, Victoria Australia
| | - Nikos Thomacos
- Department of Occupational Therapy, Monash University, Frankston, Victoria, Australia
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Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy. Plast Reconstr Surg 2022; 149:1380-1390. [PMID: 35613287 DOI: 10.1097/prs.0000000000009148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies. METHODS A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher. CONCLUSION Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Larocerie-Salgado J, Chinchalkar S, Ross DC, Gillis J, Doherty CD, Miller TA. Rehabilitation Following Nerve Transfer Surgery. Tech Hand Up Extrem Surg 2022; 26:71-77. [PMID: 34619740 DOI: 10.1097/bth.0000000000000359] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nerve transfer surgery is an important new addition to the treatment paradigm following nerve trauma. The following rehabilitation plan has been developed over the past 15 years, in an interdisciplinary, tertiary peripheral nerve program at the "Roth|McFarlane Hand and Upper Limb Centre." This center evaluates more than 400 patients with complex nerve injuries annually and has been routinely using nerve transfers since 2005. The described rehabilitation program includes input from patients, therapists, physiatrists, and surgeons and has evolved based on experience and updated science. The plan is comprised of phases which are practical, reproducible and will serve as a framework to allow other peripheral nerve programs to adapt and improve the "Roth|McFarlane Hand and Upper Limb Centre" paradigm to enhance patient outcomes.
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Affiliation(s)
- Juliana Larocerie-Salgado
- Roth| McFarlane Hand and Upper Limb Centre and the Peripheral Nerve Clinic, Western University, London, ON
| | - Shrikant Chinchalkar
- Roth| McFarlane Hand and Upper Limb Centre and the Peripheral Nerve Clinic, Western University, London, ON
| | - Douglas C Ross
- Roth| McFarlane Hand and Upper Limb Centre and the Peripheral Nerve Clinic, Western University, London, ON
| | - Joshua Gillis
- Roth| McFarlane Hand and Upper Limb Centre and the Peripheral Nerve Clinic, Western University, London, ON
| | - Christopher D Doherty
- Department of Surgery, Division of Plastic Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas A Miller
- Roth| McFarlane Hand and Upper Limb Centre and the Peripheral Nerve Clinic, Western University, London, ON
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21
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Donor activation focused rehabilitation approach to hand closing nerve transfer surgery in individuals with cervical level spinal cord injury. Spinal Cord Ser Cases 2022; 8:47. [PMID: 35487892 PMCID: PMC9055048 DOI: 10.1038/s41394-022-00512-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 01/15/2023] Open
Abstract
STUDY DESIGN Case Series. OBJECTIVES To describe the donor activation focused rehabilitation approach (DAFRA) in the setting of the hand closing nerve transfers in cervical spinal cord injury (SCI) so that therapists may apply it to treatment of individuals undergoing this procedure. SETTING United States of America-Academic Level 1 Trauma Center. METHODS We reviewed the records of individuals with cervical SCI who underwent nerve transfer to restore hand closing and post-surgery DAFRA therapy at our institution. The three post-surgery phases of DAFRA included (1) early phase (0-12 months) education, limb preparation, and donor activation exercises, (2) middle phase (12-24 months) volitional recipient muscle activation and (3) late phase (18 + months) strengthening and incorporation of motion in activities of daily living. RESULTS Subtle gains in hand closing were first observed at a mean of 8.4 months after hand closing nerve transfer surgery. Remarkable improvements including discontinuation of assistive devices, independence with feeding and urinary function, and measurable grip were observed. Function continued to improve slowly for one to two more years. CONCLUSIONS A deliberate, slow-paced (monthly for >2 years post-surgery) and incremental therapy program-DAFRA-can be used to improve outcomes after nerve transfer to restore hand closing in cervical SCI. SPONSORSHIP This work was made possible by funding from the Craig H. Neilsen Foundation Spinal Cord Injury Research on the Translation Spectrum (SCIRTS) Grant: Nerve Transfers to Restore Hand Function in Cervical Spinal Cord Injury (PI: Ida Fox).
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22
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Brogan DM, Osei DA, Colorado BS, Sneag DB, Van Voorhis A, Dy CJ. Team Approach: Management of Brachial Plexus Injuries. JBJS Rev 2022; 10:01874474-202204000-00005. [PMID: 35427254 DOI: 10.2106/jbjs.rvw.21.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Traumatic brachial plexus injuries are relatively rare but potentially devastating injuries with substantial functional, psychological, and economic consequences. » Prompt referral (ideally within 6 weeks of injury) to a center with a team of experts experienced in the diagnosis and management of these injuries is helpful to achieving optimal outcomes. » Preoperative and intraoperative decision-making to diagnose and plan reconstructive procedures is complex and must take into account a number of factors, including the time from injury, concomitant injuries, preservation of cervical nerve roots, and the availability of intraplexal and extraplexal donor nerves for nerve transfer. » A team approach is essential to ensure accurate localization of the pathology before surgery and to maximize rehabilitation after surgery, necessitating close contact between the surgical team, physiatrists, radiologists, and therapists.
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Affiliation(s)
- David M Brogan
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Berdale S Colorado
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Anna Van Voorhis
- Program in Occupational Therapy, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher J Dy
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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Manna M, Mortenson WB, Kardeh B, Douglas S, Marks C, Krauss EM, Berger MJ. Patient perspectives and self-rated knowledge of nerve transfer surgery for restoring upper limb function in spinal cord injury. PM R 2022; 15:579-586. [PMID: 35352495 DOI: 10.1002/pmrj.12811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 02/06/2022] [Accepted: 03/16/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nerve transfer surgery has the potential to restore upper limb function in patients with spinal cord injury (SCI); however, there has been limited exploration of patient perception of nerve transfer. OBJECTIVE To explore the perspectives of patients with chronic SCI (>2 years from injury) on nerve transfer surgery, and to determine if an educational intervention improved participants' perceived knowledge levels about the procedure. DESIGN Mixed-methods study including qualitative semi-structured interviews and self-reported rating scales. Pre- and post-interviews were completed following an educational presentation. SETTING Two local SCI clinics. PARTICIPANTS Ten patients with chronic traumatic SCI and neurological level of injury C3-C7 (motor complete or incomplete), recruited via snowball sampling (six male, four female). INTERVENTION An educational slide presentation on nerve transfer concepts. MAIN OUTCOME MEASURES The primary study outcome measure is the participants' responses to interview questions. The secondary study outcome measure is their self-reported knowledge levels of nerve transfer before and after education. RESULTS Regaining upper limb function was a priority for all participants. Although most participants had heard of nerve transfer, none were offered it at the time of their SCI, and only two stated that they had any peers who had undergone the procedure. The educational module significantly increased self-rated scores on understanding of nerve transfer (p < .05). Although all participants were open to nerve transfer after the educational module, they described weighing different factors, including (1) potential for loss versus gain of function, (2) inadequate knowledge about nerve transfer, (3) recovery time, and (4) determining their eligibility for the surgery. CONCLUSIONS These findings suggest that people with SCI have limited understanding of nerve transfer as a potential option and would benefit from educational opportunities to help them make informed decisions. This study may inform the development of patient resources to improve pre-surgical consultation and informed decision-making.
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Affiliation(s)
- Mariam Manna
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Ben Mortenson
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; International Collaboration on Repair Discoveries (ICORD),Vancouver, British Columbia, Canada; GF Strong Rehabilitation Research Program, Vancouver, British Columbia, Canada
| | - Bahareh Kardeh
- Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Rehabilitation Research Program, GF Strong Rehabilitation Research Program, Vancouver, British Columbia, Canada
| | - Sam Douglas
- University of Victoria, Victoria, British Columbia, Canada
| | - Chris Marks
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Emily M Krauss
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Victoria, British Columbia, Canada
| | - Michael J Berger
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Division of Physical Medicine & Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Doi K, Yii Chia DS, Hattori Y, Sakamoto S. Virtual Rehabilitation of Elbow Flexion Following Nerve Transfer Reconstruction for Brachial Plexus Injuries Using the Single-Joint Hybrid Assisted Limb. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:97-102. [PMID: 35434571 PMCID: PMC9005380 DOI: 10.1016/j.jhsg.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022] Open
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Tsang P, Larocerie-Salgado J, MacDermid JC, Miller TA, Doherty C, Ross DC. Postoperative management and rehabilitation after the supercharged end-to-side anterior interosseous nerve to ulnar motor nerve transfer: A report of 3 cases. J Hand Ther 2021; 34:469-478. [PMID: 32571598 DOI: 10.1016/j.jht.2020.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/23/2020] [Accepted: 03/28/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Compressive ulnar neuropathy at the elbow is the second most common compressive neuropathy. Nerve transfers are used for severe ulnar neuropathies as a means of facilitating recovery. Hand therapy and rehabilitation after nerve transfers have not been extensively explored. PURPOSE OF THE STUDY The aim of this repeated case study was to describe the responses, functional outcome, and neuromuscular health of three participants after the supercharged end-to-side (SETS) anterior interosseous nerve (AIN) to ulnar motor nerve transfer do describe the hand therapy and recovery of 3 cases reflecting different recovery potential mediators, trajectories, and outcomes. STUDY DESIGN Repeated case study. METHODS Three participants of similar age (76-80 years) that had severe ulnar neuropathy who underwent surgical treatment including a SETS AIN to ulnar motor nerve surgery were purposively selected from an ongoing clinical trial, based on their response to the surgical and the rehabilitation intervention (large, moderate, and small improvements). Clinical evaluations included measuring range of motion, strength testing, and clinical tests (ie, Egawa's sign) and, subjective assessment of rehabilitation adherence., Quick Disability of Arm, Shoulder and Hand and decomposition-based quantitative electromyography were performed at >23 months to evaluate patients. RESULTS All the three participants completed the surgical and hand therapy interventions, demonstrating a variable course of recovery and functional outcomes. The Quick Disability of Arm, Shoulder and Hand scores (>23 months) for participants A, B, and C were 68, 30, and 18, respectively. The person with the least improvement had idiopathic Parkinson's disease, dyslipidemia, history of depression, and gout. Comparison across cases suggested that the comorbidities, longer time from neuropathy to the surgical intervention, and psychosocial barriers to exercise and rehabilitation adherence influenced the recovery process. The participants with the best outcomes demonstrated improvements in his lower motor neurons or motor unit counts (109 and 18 motor units in the abductor digiti minimi (ADM) and first dorsal interosseous, respectively) and motor unit stability (39.5% and 37.6% near-fiber jiggle in the ADM and first dorsal interosseous, respectively). The participant with moderate response to the interventions had a motor unit count of 93 for the ADM muscle. We were unable to determine motor unit counts and measurements from the participant with the poorest outcomes due to his physical limitations. CONCLUSIONS SETS AIN to ulnar motor nerve followed by multimodal hand therapy provides measurable improvements in neurophysiology and function, although engagement in hand therapy and outcomes appear to be mediated by comorbid physical and psychosocial health.
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Affiliation(s)
- Philemon Tsang
- Department of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; Hand and Upper Limb Centre Clinical Research Lab, St. Joseph's Health Centre, London, Ontario, Canada.
| | | | - Joy C MacDermid
- Department of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; Hand and Upper Limb Centre Clinical Research Lab, St. Joseph's Health Centre, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Thomas A Miller
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Christopher Doherty
- Division of Plastic Surgery, University of British Columbia, London, Ontario, Canada
| | - Douglas C Ross
- Division of Plastic Surgery, Department of Surgery, Roth-McFarlane Hand & Upper Limb Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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McInnes CW, Ha AY, Power HA, Tung TH, Moore AM. Femoral nerve decompression and sartorius-to-quadriceps nerve transfers for partial femoral nerve injury: a cadaveric study and early case series. J Neurosurg 2021; 135:904-911. [PMID: 33157531 DOI: 10.3171/2020.6.jns20251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Partial femoral nerve injuries cause significant disability with ambulation. Due to their more proximal and superficial location, sartorius branches are often spared in femoral nerve injuries. In this article, the authors report the benefits of femoral nerve decompression, demonstrate the feasibility of sartorius-to-quadriceps nerve transfers in a cadaveric study, describe the surgical technique, and report clinical results. METHODS Four fresh-frozen cadaveric lower limbs were dissected for anatomical analysis of the sartorius nerve. In addition, a retrospective review of patients with partial femoral nerve injuries treated with femoral nerve decompression and sartorius-to-quadriceps nerve transfers was conducted. Pre- and postoperative knee extension Medical Research Council (MRC) grades and pain scores (visual analog scale) were collected. RESULTS Up to 6 superficial femoral branches innervate the sartorius muscle just distal to the inguinal ligament. Each branch yielded an average of 672 nerve fibers (range 99-1850). Six patients underwent femoral nerve decompression and sartorius-to-quadriceps nerve transfers. Four patients also had concomitant obturator-to-quadriceps nerve transfers. At final follow-up (average 13.4 months), all patients achieved MRC grade 4-/5 or greater knee extension. The average preoperative pain score was 5.2, which decreased to 2.2 postoperatively (p = 0.03). CONCLUSIONS Femoral nerve decompression and nerve transfer using sartorius branches are a viable tool for restoring function in partial femoral nerve injuries. Sartorius branches serve as ideal donors in quadriceps nerve transfers because they are expendable, are close to their recipients, and have an adequate supply of nerve fibers.
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Affiliation(s)
- Colin W McInnes
- 1Department of Surgery, Division of Plastic Surgery, Fraser Health Authority/University of British Columbia, New Westminster, British Columbia, Canada
| | - Austin Y Ha
- 2Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Hollie A Power
- 3Department of Surgery, Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada; and
| | - Thomas H Tung
- 2Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Amy M Moore
- 4Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Cole T, Nicks R, Ferris S, Paul E, O'Brien L, Pritchard E. Outcomes after occupational therapy intervention for traumatic brachial plexus injury: A prospective longitudinal cohort study. J Hand Ther 2021; 33:528-539. [PMID: 32156574 DOI: 10.1016/j.jht.2019.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/23/2019] [Accepted: 08/28/2019] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Prospective longitudinal cohort study. INTRODUCTION Traumatic brachial plexus injuries (BPIs) can be devastating and negatively impact daily function and quality of life. Occupational therapists play an important role in rehabilitation; however, studies identifying outcomes are lacking. PURPOSE This study aims to describe outcomes including motor recovery, upper limb function, participation, pain, and quality of life for people receiving occupational therapy intervention. METHODS A convenience sample of English-speaking adults (n = 30) with a traumatic BPI, attending the clinic between December 1, 2014, to November 30, 2016, participated. Participants received occupational therapy focusing on sensorimotor retraining and activity-based rehabilitation. Data on active range of motion (goniometry), strength (Medical Research Council (MRC)), upper-limb function (UEFI15, QuickDASH), participation (PSFS), pain (Brief Pain Inventory), and quality of life (EQ-5D-3L) were collected at baseline, 3, 6, 9, and 12 months. RESULTS Elbow flexion strength showed significant improvement at all time-points, average increase 2.17 (MRC) (95% confidence interval: 1.29-3.04; P < .001) and mean final MRC grading 3.86 (standard error: 0.44). Significant improvements at 12 months were seen in: shoulder abduction strength and range, flexion strength and range, external rotation range; elbow extension strength and flexion range; thumb flexion and extension strength. Upper limb function (QuickDASH) showed significant improvement (mean change = 18.85; 95% confidence interval: 4.12-33.59; P = .02). Forearm protonation range and finger flexion strength were significantly worse. Remaining outcomes did not show significant improvement. CONCLUSIONS Occupational therapy with surgical intervention can improve strength, range, and upper limb function with people following traumatic BPI. Further investigations into impact on participation, pain, and quality of life are required.
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Affiliation(s)
- Tanya Cole
- Occupational Therapy, Alfred Health, Melbourne, Victoria, Australia.
| | - Rebecca Nicks
- Occupational Therapy, Alfred Health, Melbourne, Victoria, Australia; Occupational Therapy, Eastern Health, Melbourne, Victoria, Australia
| | - Scott Ferris
- Plastic, Hand and Faciomaxillary Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lisa O'Brien
- Occupational Therapy, Alfred Health, Melbourne, Victoria, Australia
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Lower Extremity Nerve Transfers in Acute Flaccid Myelitis Patients: A Case Series. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3699. [PMID: 34422521 PMCID: PMC8376396 DOI: 10.1097/gox.0000000000003699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
Acute flaccid myelitis (AFM) is characterized by flaccid paralysis following prodromal symptoms. Complete recovery is rare, and patients typically have residual extremity weakness. This study aimed to describe the technique and outcomes of lower extremity nerve transfers for children with AFM.
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Reply: Evaluation of Intrinsic Hand Musculature Reinnervation following Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer. Plast Reconstr Surg 2021; 148:500e-501e. [PMID: 34319289 DOI: 10.1097/prs.0000000000008248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Son WC, Kim JK, Kwon S, Kim DY. Roles of preoperative and early postoperative electrodiagnosis in brachial plexus injury patients undergoing nerve transfer operations: retrospective feasibility study. J Int Med Res 2021; 49:3000605211006610. [PMID: 33866837 PMCID: PMC8054219 DOI: 10.1177/03000605211006610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this retrospective observational study was to assess the
feasibility of electrodiagnostic parameters, perioperatively, and to
discover optimal values as prognostic factors for patients with brachial
plexus injury undergoing nerve transfer operations. Methods We retrospectively reviewed the records of 11 patients who underwent nerve
transfer surgery. The patients underwent perioperative electrodiagnosis
(EDX) before and approximately 6 months after surgery. We evaluated the
compound muscle action potential (CMAP) ratio, motor unit recruitment, and
their interval changes. To evaluate motor strength, we used the Medical
Research Council (MRC) grade, 6 and 12 months after surgery. We evaluated
the relationships between improved CMAP ratio, and motor unit recruitment
and MRC grade changes 6 and 12 months postoperatively. Results All parameters increased significantly after surgery. The CMAP ratio
improvement 6 months after surgery correlated with the MRC grade change from
baseline to 12 months, with a correlation coefficient of 0.813. Conclusion EDX parameters improved significantly postoperatively, and the CMAP ratio
improvement 6 months after surgery correlated with the clinical outcomes at
1 year. The results of perioperative EDX might help establish long-term
treatment plans for patients who undergo nerve transfer surgery.
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Affiliation(s)
- Woo Chul Son
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Kwang Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sara Kwon
- Department of Rehabilitation Medicine, Kaiser Hospital, Gu-ri, Korea
| | - Dae Yul Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Five Reliable Nerve Transfers for the Treatment of Isolated Upper Extremity Nerve Injuries. Plast Reconstr Surg 2021; 147:830e-845e. [PMID: 33890905 DOI: 10.1097/prs.0000000000007865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
LEARNING OBJECTIVES After studying this article and accompanying videos, the participant should be able to: 1. Understand and apply the principles of nerve transfer surgery for nerve injuries. 2. Discuss important considerations when performing nerve transfers, such as aspects of surgical technique and perioperative decision-making. 3. Understand indications for end-to-end versus supercharged reverse end-to-side nerve transfers. 4. Understand an algorithm for treating nerve injuries to include the indications and surgical techniques of five nerve transfers commonly performed for the treatment of isolated upper extremity nerve injuries. 5. Understand the outcomes and postoperative management of the discussed nerve transfers. SUMMARY Nerve transfers are gaining wide acceptance because of their superior results in the management of many nerve injuries of the upper extremity. This article presents five nerve transfers for the treatment of isolated nerve injuries in the authors' upper extremity nerve practice that offer reliable results. Indications, surgical techniques, outcomes, and postoperative management are reviewed. To maximize functional outcomes in patients with nerve injuries, the treatment should be individualized to the patient, and the principles for nerve transfers as described herein should be considered.
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O'Brien AL, West JM, Zewdu A, Grignol VP, Scharschmidt TJ, Moore AM. Nerve transfers to restore femoral nerve function following oncologic nerve resection. J Surg Oncol 2021; 124:33-40. [PMID: 33831232 DOI: 10.1002/jso.26487] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Advances in the care of soft-tissue tumors, including imaging capabilities and adjuvant radiation therapy, have broadened the indications and opportunities to pursue surgical limb salvage. However, peripheral nerve involvement and femoral nerve resection can still result in devastating functional outcomes. Nerve transfers offer a versatile solution to restore nerve function following tumor resection. METHODS Two cases were identified by retrospective review. Patient and disease characteristics were gathered. Preoperative and postoperative motor function were assessed using the Medical Research Council Muscle Scale. Patient-reported pain levels were assessed using the numeric rating scale. RESULTS Nerve transfers from the obturator and sciatic nerve were employed to restore knee extension. Follow up for Case 1 was 24 months, 8 months for Case 2. In both patients, knee extension and stabilization of gait without bracing was restored. Patient also demonstrated 0/10 pain (an average improvement of 5 points) with decreased neuromodulator and pain medication use. CONCLUSION Nerve transfers can restore function and provide pain control benefits and ideally are performed at the time of tumor extirpation. This collaboration between oncologic and nerve surgeons will ultimately result in improved functional recovery and patient outcomes.
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Affiliation(s)
- Andrew L O'Brien
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Julie M West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Abbie Zewdu
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Valerie P Grignol
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas J Scharschmidt
- Department of Orthopaedic Surgery, The Ohio State University James Wexner Medical Center, Columbus, Ohio, USA
| | - Amy M Moore
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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de Santana Chagas AC, Wanderley D, de Oliveira Ferro JK, Alves de Moraes A, Morais de Souza FH, da Silva Tenório A, Araújo de Oliveira D. Physical therapeutic treatment for traumatic brachial plexus injury in adults: A scoping review. PM R 2021; 14:120-150. [PMID: 33543603 DOI: 10.1002/pmrj.12566] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/26/2021] [Indexed: 12/27/2022]
Abstract
Traumatic brachial plexus injury (BPI) is one of the most disabling injuries of the upper extremity, often requiring specialized treatment and a prolonged rehabilitation period. This scoping review was carried out to identify and describe the physical therapy modalities applied in the rehabilitation of adult individuals with BPI. Electronic databases, gray literature, and reference lists were searched, and studies meeting the following eligibility criteria were included: (a) interventions including any physical therapy modality; (b) individuals age ≥18 years old; and (c) a clinical diagnosis of BPI. The literature search yielded 681 articles of which 49 met the inclusion criteria and had their outcomes, treatment parameters, and the differences between conservative and pre- and postoperative treatment phases analyzed. The most commonly used physical therapy interventions were in the subfields of kinesiotherapy (ie, involving range of motion exercises, muscle stretching, and strengthening), electrothermal and phototherapy, manual therapy, and sensory re-education strategies. Although several physical therapy modalities were identified for the treatment of BPI in this scoping review, the combination of low levels of evidence and the identified gaps regarding the treatment parameters challenge the reproducibility of such treatments in clinical practice. Therefore, future controlled clinical trials with clearer treatment protocols for individuals with BPI are needed.
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Affiliation(s)
| | - Débora Wanderley
- Department of Physiotherapy, Federal University of Pernambuco, Pernambuco, Brazil
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Supercharge End-to-Side Anterior Interosseous-to-Ulnar Motor Nerve Transfer Restores Intrinsic Function in Cubital Tunnel Syndrome. Plast Reconstr Surg 2020; 146:808-818. [PMID: 32590517 DOI: 10.1097/prs.0000000000007167] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer offers a viable option to enhance recovery of intrinsic function following ulnar nerve injury. However, in the setting of chronic ulnar nerve compression where the timing of onset of axonal loss is unclear, there is a deficit in the literature on outcomes after supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer. METHODS A retrospective study of patients who underwent supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer for severe cubital tunnel syndrome over a 5-year period was performed. The primary outcomes were improvement in first dorsal interosseous Medical Research Council grade at final follow-up and time to reinnervation. Change in key pinch strength; grip strength; and Disabilities of the Arm, Shoulder and Hand questionnaire scores were also evaluated using paired t tests and Wilcoxon signed rank tests. RESULTS Forty-two patients with severe cubital tunnel syndrome were included in this study. Other than age, there were no significant clinical or diagnostic variables that were predictive of failure. There was no threshold of compound muscle action potential amplitude below which supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer was unsuccessful. CONCLUSIONS This study provides the first cohort of outcomes following supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer in chronic ulnar compression neuropathy alone and underscores the importance of appropriate patient selection. Prospective cohort studies and randomized controlled trials with standardized outcome measures are required. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Chen H, Meng D, Xie Z, Yin G, Hou C, Lin H. Transfer of Sciatic Nerve Motor Branches in High Femoral Nerve Injury: A Cadaver Feasibility Study and Clinical Case Report. Oper Neurosurg (Hagerstown) 2020; 19:E244-E250. [PMID: 32459839 DOI: 10.1093/ons/opaa131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/19/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Femoral nerve injury causes knee dysfunction, and high femoral nerve injury is difficult to repair. OBJECTIVE To evaluate the anatomic feasibility of transferring the sciatic nerve motor branches in high femoral nerve injury. METHODS The femoral nerve was exposed in both lower extremities of 3 adult fresh-frozen cadavers; each branch was noninvasively dissected to its proximal nerve fiber intersection point and distal muscle entry point. The branches of the sciatic nerve were also exposed. The length, diameter, and number of myelinated fibers were measured in each femoral and sciatic nerve branch. The feasibility of tension-free direct suture between the femoral and sciatic nerve branches was evaluated. One patient was treated with transfer of a nerve branch innervating the semitendinosus muscle to the femoral nerve branch and was followed up for 18 mo. RESULTS The diameters and numbers of myelinated fibers in the femoral nerve branches matched those of the sciatic nerve branches. In the single patient, a combined femoral nerve bundle (comprising the rectus femoris and vastus lateralis branches) was used as a graft. The branch of the sciatic nerve was sutured with the muscle branch of the femoral by using a sural nerve as a nerve graft. The knee joint straightening strength reached medical research council grade 4+. CONCLUSION The proximal motor branches of the sciatic nerve may be transferred as donor nerves to repair high femoral nerve injury. A femoral nerve bundle comprising the rectus femoris and vastus lateralis branches may be used as the receptor nerve.
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Affiliation(s)
- Huihao Chen
- Department of Orthopedic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Depeng Meng
- Department of Orthopedic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Zheng Xie
- Department of Orthopedic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, People's Republic of China
| | - Gang Yin
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Chunlin Hou
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Haodong Lin
- Department of Orthopedic Surgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
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Chagas ACDS, Wanderley D, Barboza PJM, Martins JVP, de Moraes AA, de Souza FHM, de Oliveira DA. Proprioceptive neuromuscular facilitation compared to conventional physiotherapy for adults with traumatic upper brachial plexus injury: A protocol for a randomized clinical trial. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2020; 26:e1873. [PMID: 32790955 DOI: 10.1002/pri.1873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/13/2020] [Accepted: 07/24/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND Traumatic upper plexus injury affects daily living activities performance and participation of individuals. Physical therapy treatment has a fundamental role on functional recovery, but it is still an unexplored and challenging field. AIM To develop a protocol to evaluate the efficacy of Proprioceptive Neuromuscular Facilitation (PNF) compared to conventional physiotherapy (CPT group) on functionality and quality of life. METHODS A committee was formed by four physical therapists to develop the treatment protocol. A Delphi study was carried out in order to quantify the level of agreement. A protocol for a randomized controlled trial was proposed to evaluate the effectiveness of the protocol in improving functionality and quality of life, according Consolidated Standards of Reporting Trials. Participants will be randomly assigned (1:1) to PNF or CPT group and two weekly sessions will be carried out for 12 months postsurgery, with a three-month follow-up. The main outcome measurements are: upper limb functionality, quality of life, range of motion, muscle strength, tactile sensitivity, and pain, which will be assessed at baseline, on the 6th, 9th, and 12th months postsurgery. RESULT A PNF protocol was developed for traumatic upper brachial plexus injury, consisting of 11 illustrated exercises, three for immediate postoperative and eight for postoperative. Biomechanical objectives, observations, positions of patients and therapists and PNF principles, procedures and techniques have been described. An 80% agreement on all items in the first round of the Delphi study was achieved. CONCLUSION A protocol based on the PNF-concept was developed with the aim of improving the functionality and quality of life of individuals undergoing nerve transfer after traumatic injury to the upper plexus. The detailed description of a physical therapy treatment protocol through an appropriate method will allow its use in clinical practice and in future studies with this population.
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Affiliation(s)
| | - Débora Wanderley
- Department of Physiotherapy, Federal University of Pernambuco, Recife, Brazil
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38
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Refining Indications for the Supercharge End-to-Side Anterior Interosseous to Ulnar Motor Nerve Transfer in Cubital Tunnel Syndrome. Plast Reconstr Surg 2020; 145:106e-116e. [DOI: 10.1097/prs.0000000000006399] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Madison RD, Robinson GA. Muscle-Derived Extracellular Vesicles Influence Motor Neuron Regeneration Accuracy. Neuroscience 2019; 419:46-59. [PMID: 31454553 DOI: 10.1016/j.neuroscience.2019.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/13/2019] [Accepted: 08/14/2019] [Indexed: 01/06/2023]
Abstract
Extracellular vesicles are lipid bilayer-enclosed extracellular structures. Although the term extracellular vesicles is quite inclusive, it generally refers to exosomes (<200 nm), and microvesicles (~100-1000 nm). Such vesicles are resistant to degradation and can contain proteins, lipids, and nucleic acids. Although it was previously thought that the primary purpose of such vesicles was to rid cells of unwanted components, it is now becoming increasingly clear that they can function as intercellular messengers, sometimes operating over long distances. As such, there is now intense interest in extracellular vesicles in fields as diverse as immunology, cell biology, cancer, and more recently, neuroscience. The influence that such extracellular vesicles might exert on peripheral nerve regeneration is just beginning to be investigated. In the current studies we show that muscle-derived extracellular vesicles significantly influence the anatomical accuracy of motor neuron regeneration in the rat femoral nerve. These findings suggest a basic cellular mechanism by which target end-organs could guide their own reinnervation following nerve injury.
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Affiliation(s)
- Roger D Madison
- Research Service of the Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Grant A Robinson
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA
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Wilcox M, Brown H, Johnson K, Sinisi M, Quick TJ. An assessment of fatigability following nerve transfer to reinnervate elbow flexor muscles. Bone Joint J 2019; 101-B:867-871. [PMID: 31256676 DOI: 10.1302/0301-620x.101b7.bjj-2019-0005.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation. PATIENTS AND METHODS This retrospective cohort study included 12 patients who underwent Oberlin nerve transfer in an attempt to restore flexion of the elbow following brachial plexus injury. There were ten men and two women with a mean age of 45.5 years (27 to 69). The mean follow-up was 58 months (28 to 100). Repeated and sustained isometric contractions of the elbow flexors were used to assess fatigability of reinnervated muscle. The strength of elbow flexion was measured using a static dynamometer (KgF) and surface electromyography (sEMG). Recordings were used to quantify and characterize fatigability of the reinnervated elbow flexor muscles compared with the uninjured contralateral side. RESULTS The mean peak force of elbow flexion was 7.88 KgF (sd 3.80) compared with 20.65 KgF (sd 6.88) on the contralateral side (p < 0.001). Reinnervated elbow flexor muscles (biceps brachialis) showed sEMG evidence of fatigue earlier than normal controls with sustained (60-second) isometric contraction. Reinnervated elbow flexor muscles also showed a trend towards a faster twitch muscle fibre type. CONCLUSION The assessment of motor outcomes must involve more than peak force alone. Reinnervated muscle shows a shift towards fast twitch fibres following reinnervation with an earlier onset of fatigue. Our findings suggest that fatigue is a clinically relevant characteristic of reinnervated muscle. Adoption of these metrics into clinical practice and the assessment of outcome could allow a more meaningful comparison to be made between differing forms of treatment and encourage advances in the management of motor recovery following nerve transfer. Cite this article: Bone Joint J 2019;101-B:867-871.
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Affiliation(s)
- M Wilcox
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, Stanmore, UK.,University College London Centre for Nerve Engineering, London, UK
| | - H Brown
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, Stanmore, UK.,University College London Centre for Nerve Engineering, London, UK
| | - K Johnson
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - M Sinisi
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - T J Quick
- Peripheral Nerve Injury Research Unit, Royal National Orthopaedic Hospital, Stanmore, UK.,University College London Centre for Nerve Engineering, London, UK
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Power HA, Fox IK, Kahn LC, Mackinnon SE. Restoration of Sensation and Thumb Opposition Using Nerve Transfers Following Resection of a Synovial Sarcoma of the Median Nerve. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2019. [DOI: 10.1016/j.jhsg.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Verma CV, Yardi S, Puri V, Vora T. Patients’ perception of quality of life after traumatic brachial plexus injury – a qualitative study. HAND THERAPY 2019. [DOI: 10.1177/1758998319832326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Advancements in reconstructive surgery for traumatic brachial plexus injury explain the need for better rehabilitation programmes. Therefore, an understanding of an individual patient’s perception through their journey of treatment for a traumatic brachial plexus injury is needed. Methods Thirteen patients with traumatic brachial plexus injury were selected using non-probability purposive sampling. Data were collected in the form of in-depth face-to-face interviews in a clinic setting of a tertiary government hospital using an explorative qualitative method. An interview guide comprising open-ended, nondirective semi structured questions was used and data were analyzed using an interpretative phenomenological approach. Results Eleven subthemes under the overarching theme of patient perception were identified. These subthemes illustrate perception of each individual participants’ journey of treatment for traumatic brachial plexus injury. Conclusion Our study following a qualitative approach throws light on the impact of injury and an adult individual’s perception and may thereby help to develop a more comprehensive and holistic approach towards patient care.
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Affiliation(s)
- Chhaya V Verma
- Physiotherapy School & Center, TNMC & BYL Nair Hospital, Mumbai, India
| | - Sujata Yardi
- School of Physiotherapy, DY Patil University, Navi Mumbai, India
| | - Vinita Puri
- Department of Plastic & Reconstructive Surgery, GSMC & KEM Hospital, Mumbai, India
| | - Tanvee Vora
- Physiotherapy School & Center, TNMC & BYL Nair Hospital, Mumbai, India
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Sturma A, Hruby LA, Prahm C, Mayer JA, Aszmann OC. Rehabilitation of Upper Extremity Nerve Injuries Using Surface EMG Biofeedback: Protocols for Clinical Application. Front Neurosci 2018; 12:906. [PMID: 30564090 PMCID: PMC6288367 DOI: 10.3389/fnins.2018.00906] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/19/2018] [Indexed: 11/13/2022] Open
Abstract
Motor recovery following nerve transfer surgery depends on the successful re-innervation of the new target muscle by regenerating axons. Cortical plasticity and motor relearning also play a major role during functional recovery. Successful neuromuscular rehabilitation requires detailed afferent feedback. Surface electromyographic (sEMG) biofeedback has been widely used in the rehabilitation of stroke, however, has not been described for the rehabilitation of peripheral nerve injuries. The aim of this paper was to present structured rehabilitation protocols in two different patient groups with upper extremity nerve injuries using sEMG biofeedback. The principles of sEMG biofeedback were explained and its application in a rehabilitation setting was described. Patient group 1 included nerve injury patients who received nerve transfers to restore biological upper limb function (n = 5) while group 2 comprised patients where biological reconstruction was deemed impossible and hand function was restored by prosthetic hand replacement, a concept today known as bionic reconstruction (n = 6). The rehabilitation protocol for group 1 included guided sEMG training to facilitate initial movements, to increase awareness of the new target muscle, and later, to facilitate separation of muscular activities. In patient group 2 sEMG biofeedback helped identify EMG activity in biologically "functionless" limbs and improved separation of EMG signals upon training. Later, these sEMG signals translated into prosthetic function. Feasibility of the rehabilitation protocols for the two different patient populations was illustrated. Functional outcome measures were assessed with standardized upper extremity outcome measures [British Medical Research Council (BMRC) scale for group 1 and Action Research Arm Test (ARAT) for group 2] showing significant improvements in motor function after sEMG training. Before actual movements were possible, sEMG biofeedback could be used. Patients reported that this visualization of muscle activity helped them to stay motivated during rehabilitation and facilitated their understanding of the re-innervation process. sEMG biofeedback may help in the cognitively demanding process of establishing new motor patterns. After standard nerve transfers individually tailored sEMG biofeedback can facilitate early sensorimotor re-education by providing visual cues at a stage when muscle activation cannot be detected otherwise.
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Affiliation(s)
- Agnes Sturma
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Health Assisting Engineering, University of Applied Sciences FH Campus Wien, Vienna, Austria.,Neuromechanics and Rehabilitation Technology Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Laura A Hruby
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Cosima Prahm
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes A Mayer
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Chinchalkar SJ, Larocerie-Salgado J, Cepek J, Grenier ML. The Use of Dynamic Assist Orthosis for Muscle Reeducation following Brachial Plexus Injury and Reconstruction. J Hand Microsurg 2018; 10:172-177. [PMID: 30483028 DOI: 10.1055/s-0038-1642068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 03/07/2018] [Indexed: 10/17/2022] Open
Abstract
Therapeutic management of brachial plexus injuries remains complex. The impact of brachial plexus injuries on everyday human functioning should not be underestimated. Early active-assisted range of motion following such injuries may prevent myostatic contractures, minimize muscle atrophy, facilitate muscle fiber recruitment, and enable a faster return to baseline strength levels. The dynamic assist elbow flexion orthosis proposed is designed to provide patients with a graded system for muscle reeducation and function. No clinical data are currently available on the use of this orthosis design; however, this article presents a treatment option based on sound clinical reasoning to facilitate rehabilitation following this devastating injury.
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Affiliation(s)
- Shrikant J Chinchalkar
- Roth-McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada
| | | | - Jeremy Cepek
- Schullic School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Moore AM, Krauss EM, Parikh RP, Franco MJ, Tung TH. Femoral nerve transfers for restoring tibial nerve function: an anatomical study and clinical correlation: a report of 2 cases. J Neurosurg 2018; 129:1024-1033. [DOI: 10.3171/2017.5.jns163076] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Sciatic nerve injuries cause debilitating functional impairment, particularly when the injury mechanism and level preclude reconstruction with primary grafting. The purpose of this study was to demonstrate the anatomical feasibility of nerve transfers from the distal femoral nerve terminal branches to the tibial nerve and to detail the successful restoration of tibial function using the described nerve transfers.Six cadaveric legs were dissected for anatomical analysis and the development of tension-free nerve transfers from femoral nerve branches to the tibial nerve. In 2 patients with complete tibial and common peroneal nerve palsies following sciatic nerve injury, terminal branches of the femoral nerve supplying the vastus medialis and vastus lateralis muscles were transferred to the medial and lateral gastrocnemius branches of the tibial nerve. Distal sensory transfer of the saphenous nerve to the sural nerve was also performed. Patients were followed up for lower-extremity motor and sensory recovery up to 18 months postoperatively.Consistent branching patterns and anatomical landmarks were present in all dissection specimens, allowing for reliable identification, neurolysis, and coaptation of donor femoral and saphenous nerve branches to the recipients. Clinically, the patients obtained Medical Research Council Grade 3 and 3+ plantar flexion by 18 months postoperatively. Improved strength was accompanied by improved ambulation in both patients and by a return to competitive sports in 1 patient. Sensory recovery was demonstrated by an advancing Tinel sign in both patients.This study illustrates the clinical success and anatomical feasibility of femoral nerve to tibial nerve transfers after proximal sciatic nerve injury.
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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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