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Hibbard EA, Zhou L, Yang CZ, Venkudusamy K, Montoya Y, Olivarez A, Bittner GD, Sengelaub DR. Polyethylene glycol fusion repair of severed rat sciatic nerves reestablishes axonal continuity and reorganizes sensory terminal fields in the spinal cord. Neural Regen Res 2025; 20:2095-2107. [PMID: 38845228 DOI: 10.4103/nrr.nrr-d-23-01845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/16/2024] [Indexed: 09/11/2024] Open
Abstract
JOURNAL/nrgr/04.03/01300535-202507000-00030/figure1/v/2024-09-09T124005Z/r/image-tiff Peripheral nerve injuries result in the rapid degeneration of distal nerve segments and immediate loss of motor and sensory functions; behavioral recovery is typically poor. We used a plasmalemmal fusogen, polyethylene glycol (PEG), to immediately fuse closely apposed open ends of severed proximal and distal axons in rat sciatic nerves. We have previously reported that sciatic nerve axons repaired by PEG-fusion do not undergo Wallerian degeneration, and PEG-fused animals exhibit rapid (within 2-6 weeks) and extensive locomotor recovery. Furthermore, our previous report showed that PEG-fusion of severed sciatic motor axons was non-specific, i.e., spinal motoneurons in PEG-fused animals were found to project to appropriate as well as inappropriate target muscles. In this study, we examined the consequences of PEG-fusion for sensory axons of the sciatic nerve. Young adult male and female rats (Sprague-Dawley) received either a unilateral single cut or ablation injury to the sciatic nerve and subsequent repair with or without (Negative Control) the application of PEG. Compound action potentials recorded immediately after PEG-fusion repair confirmed conduction across the injury site. The success of PEG-fusion was confirmed through Sciatic Functional Index testing with PEG-fused animals showing improvement in locomotor function beginning at 35 days postoperatively. At 2-42 days postoperatively, we anterogradely labeled sensory afferents from the dorsal aspect of the hindpaw following bilateral intradermal injection of wheat germ agglutinin conjugated horseradish peroxidase. PEG-fusion repair reestablished axonal continuity. Compared to unoperated animals, labeled sensory afferents ipsilateral to the injury in PEG-fused animals were found in the appropriate area of the dorsal horn, as well as inappropriate mediolateral and rostrocaudal areas. Unexpectedly, despite having intact peripheral nerves, similar reorganizations of labeled sensory afferents were also observed contralateral to the injury and repair. This central reorganization may contribute to the improved behavioral recovery seen after PEG-fusion repair, supporting the use of this novel repair methodology over currently available treatments.
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Affiliation(s)
- Emily A Hibbard
- Program in Neuroscience, Indiana University, Bloomington, IN, USA
| | - Liwen Zhou
- Department of Neuroscience, University of Texas at Austin, Austin, TX, USA
| | - Cathy Z Yang
- Department of Neuroscience, University of Texas at Austin, Austin, TX, USA
| | | | - Yessenia Montoya
- Department of Neuroscience, University of Texas at Austin, Austin, TX, USA
| | - Alexa Olivarez
- Department of Neuroscience, University of Texas at Austin, Austin, TX, USA
| | - George D Bittner
- Department of Neuroscience, University of Texas at Austin, Austin, TX, USA
| | - Dale R Sengelaub
- Program in Neuroscience, Indiana University, Bloomington, IN, USA
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Wu RT, Chuieng-Yi Lu J. Nerve Autograft: Preservation of a Lost Art. Hand Clin 2024; 40:347-356. [PMID: 38972679 DOI: 10.1016/j.hcl.2024.04.004] [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] [Indexed: 07/09/2024]
Abstract
Nerve autografts involve the transplantation of a segment of the patient's own nerve to bridge a nerve gap. Autografts provide biological compatibility, support for axonal regeneration, and the ability to provide an anatomic scaffold for regrowth that other modalities may not match. Disadvantages of the autograft include donor site morbidity and the extra operative time needed to harvest the graft. Nevertheless, nerve autografts such as the sural nerve remain the gold standard in reconstructing nerve gaps, but a multitude of factors need to be favorable in order to garner reliable, consistent outcomes.
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Affiliation(s)
- Robin T Wu
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Standford, CA 94305, USA
| | - Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Taoyuan City, 333 Taiwan; Chang Gung University, Taoyuan, Taiwan.
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Lin JAJ, Lu JCY, Chang TNJ, Sakarya AH, Chuang DCC. Long-Term Outcome of 118 Acute Total Brachial Plexus Injury Patients Using Free Vascularized Ulnar Nerve Graft to Innervate the Median Nerve. J Reconstr Microsurg 2022; 39:279-287. [PMID: 36191593 DOI: 10.1055/s-0042-1755612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2022]
Abstract
BACKGROUND The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods. METHODS From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes. RESULTS For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN. CONCLUSION In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN). LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jennifer An-Jou Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Johnny Chuieng-Yi Lu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Tommy Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ahmet Hamdi Sakarya
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - David Chwei-Chin Chuang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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Outcomes of gracilis free-flap muscle transfers and non-free-flap procedures for restoration of elbow flexion: A systematic review. J Plast Reconstr Aesthet Surg 2022; 75:2625-2636. [PMID: 35644885 DOI: 10.1016/j.bjps.2022.04.025] [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: 08/11/2020] [Revised: 08/14/2021] [Accepted: 04/12/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion. METHODS MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines. RESULTS Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8). CONCLUSIONS Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM.
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Hibbard EA, Sengelaub DR. Intraneural Topography of Rat Sciatic Axons: Implications for Polyethylene Glycol Fusion Peripheral Nerve Repair. Front Cell Neurosci 2022; 16:852933. [PMID: 35431811 PMCID: PMC9005634 DOI: 10.3389/fncel.2022.852933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Peripheral nerve injuries are the most common type of nerve trauma. We have been working with a novel repair technique using a plasmalemmal fusogen, polyethylene glycol (PEG), to re-fuse the membranes of severed axons. PEG-fusion repair allows for immediate re-innervation of distal targets, prevents axonal degeneration, and improves behavioral recovery. PEG-fusion of severed axons is non-specific, and we have previously reported that following injury and PEG-fusion misconnections between spinal motoneurons and their distal targets were present. Surprisingly, appropriately paired proximal and distal motor axons were observed in all PEG-fused animals. We hypothesized that a topographic organization of axons contributing to the sciatic nerve could explain the incidence of appropriate connections. We traced the course of specific axon populations contributing to the sciatic nerve in young adult male and female rats. Following intraneural injection of Fast Blue into the tibial branch, labeled axons were confined to a discrete location throughout the course of the nerve. Following intramuscular injection of cholera toxin-conjugated horseradish peroxidase into the anterior tibialis, labeled axons were confined to a smaller but still discrete location throughout the nerve. In both cases, the relative locations of labeled axons were consistent bilaterally within animals, as well as across animals and sexes. Thus, the relatively consistent location of specific axon populations could allow for realignment of appropriate populations of axons, and enhanced behavioral recovery seen in PEG-fused animals. Knowing the organization of axons within the sciatic nerve promotes accurate territory realignment during repair, therefore aiding in recovery outcomes.
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Abstract
The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.
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Namazi H, Kiani M, Gholamzadeh S, Dehghanian A, Fatemeh DN. Obturator to tibial nerve transfer via saphenous nerve graft for treatment of sacral plexus root avulsions: A cadaveric study. Orthop Traumatol Surg Res 2020; 106:291-295. [PMID: 32165132 DOI: 10.1016/j.otsr.2019.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/14/2019] [Accepted: 11/19/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In cases of sacral nerve avulsion injuries, proximal nerve stumps are not available because of its protected position in pelvis, and results of nerve repair or graft are unsatisfactory. Nerve transfer can reduce the regeneration time and improve the results of recovery. HYPOTHESIS The obturator nerve transfer to the tibial nerve via saphenous nerve graft is possible and feasible. MATERIALS AND METHODS Ten male adult cadaveric lower limbs dissected to identify the location of the anterior branch of obturator nerve, the saphenous nerve and the medial gastrocnemius branch. The saphenous nerve was cut from its origin and transferred to the anterior branch of obturator nerve. As well, it was cut distally and transferred to the medial gastrocnemius branch. After nerve coaptation, surface area and fascicle count were determined by histological methods. RESULTS In all limbs, the proximal and distal stumps of saphenous nerve were reached the anterior branch of obturator and the medial gastrocnemius branch, respectively without tension. The mean of fascicle number in the anterior branch of obturator nerve, proximal and distal stump of the saphenous nerve and stump of medial gastrocnemius nerve branch were 2.90±0.99, 4.50±2.70, 4.00±2.26 and 4.30±1.25, respectively. DISCUSSION This study showed that it is possible to transfer the obturator nerve to the medial gastrocnemius branch via saphenous nerve bridge; and their histological parameters are match in a good manner. Therefore, this technique is suggested for patients with sacral nerve avulsion injuries. LEVEL OF EVIDENCE IV, case series of cadaveric study.
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Affiliation(s)
- Hamid Namazi
- Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masood Kiani
- Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saeed Gholamzadeh
- Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran
| | - Amirreza Dehghanian
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Saffari TM, Bedar M, Hundepool CA, Bishop AT, Shin AY. The role of vascularization in nerve regeneration of nerve graft. Neural Regen Res 2020; 15:1573-1579. [PMID: 32209756 PMCID: PMC7437604 DOI: 10.4103/1673-5374.276327] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Vascularization is an important factor in nerve graft survival and function. The specific molecular regulations and patterns of angiogenesis following peripheral nerve injury are in a broad complex of pathways. This review aims to summarize current knowledge on the role of vascularization in nerve regeneration, including the key regulation molecules, and mechanisms and patterns of revascularization after nerve injury. Angiogenesis, the maturation of pre-existing vessels into new areas, is stimulated through angiogenic factors such as vascular endothelial growth factor and precedes the repair of damaged nerves. Vascular endothelial growth factor administration to nerves has demonstrated to increase revascularization after injury in basic science research. In the clinical setting, vascularized nerve grafts could be used in the reconstruction of large segmental peripheral nerve injuries. Vascularized nerve grafts are postulated to accelerate revascularization and enhance nerve regeneration by providing an optimal nutritional environment, especially in scarred beds, and decrease fibroblast infiltration. This could improve functional recovery after nerve grafting, however, conclusive evidence of the superiority of vascularized nerve grafts is lacking in human studies. A well-designed randomized controlled trial comparing vascularized nerve grafts to non-vascularized nerve grafts involving patients with similar injuries, nerve graft repair and follow-up times is necessary to demonstrate the efficacy of vascularized nerve grafts. Due to technical challenges, composite transfer of a nerve graft along with its adipose tissue has been proposed to provide a healthy tissue bed. Basic science research has shown that a vascularized fascial flap containing adipose tissue and a vascular bundle improves revascularization through excreted angiogenic factors, provided by the stem cells in the adipose tissue as well as by the blood supply and environmental support. While it was previously believed that revascularization occurred from both nerve ends, recent studies propose that revascularization occurs primarily from the proximal nerve coaptation. Fascial flaps or vascularized nerve grafts have limited applicability and future directions could lead towards off-the-shelf alternatives to autografting, such as biodegradable nerve scaffolds which include capillary-like networks to enable vascularization and avoid graft necrosis and ischemia.
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Affiliation(s)
- Tiam M Saffari
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Meiwand Bedar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Caroline A Hundepool
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Ayhan E, Soldado F, Fontecha CG, Bertelli JA, Leblebicioglu G. Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study. Microsurgery 2019; 40:79-86. [PMID: 30761593 DOI: 10.1002/micr.30440] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/06/2019] [Accepted: 01/25/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury. METHODS PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed. RESULTS In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022). CONCLUSIONS Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Egemen Ayhan
- Department of Orthopaedics and Traumatology - Hand Surgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Universitari Vall Hebron, Barcelona, Spain and UCA unit, Hospital Vithas San Jose, Vitoria, Spain
| | - César G Fontecha
- Pediatric Orthopedic Unit, Vall d'Hebron Hospital. Universitat de Barcelona, Barcelona, Spain
| | - Jayme A Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Gursel Leblebicioglu
- Department of Orthopaedics and Traumatology, Division of Hand Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
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Yang KX, Zhang SH, Ge DW, Sui T, Chen HT, Cao XJ. A novel extradural nerve transfer technique by coaptation of C4 to C5 and C7 to C6 for treating isolated upper trunk avulsion of the brachial plexus. J Biomed Res 2018; 32:298-304. [PMID: 29884775 PMCID: PMC6117610 DOI: 10.7555/jbr.32.20180012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The study aimed to demonstrate the feasibility of an extradural nerve anastomosis technique for the restoration of a C5 and C6 avulsion of the brachial plexus. Nine fresh frozen human cadavers were used. The diameters, sizes, and locations of the extradural spinal nerve roots were observed. The lengths of the extradural spinal nerve roots and the distance between the neighboring nerve root outlets were measured and compared in the cervical segments. In the spinal canal, the ventral and dorsal roots were separated by the dura and arachnoid. The ventral and dorsal roots of C7 had sufficient lengths to anastomose those of C6. The ventral and dorsal of C4 had enough length to be transferred to those of C5, respectively. The feasibility of this extradural nerve anastomosis technique for restoring C5 and C6 avulsion of the brachial plexus in human cadavers was demonstrated in our anatomical study.
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Affiliation(s)
- Kai-Xiang Yang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Shao-Hua Zhang
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Da-Wei Ge
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Tao Sui
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hong-Tao Chen
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xiao-Jian Cao
- Department of Orthopaedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
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Potter SM, Ferris SI. Reliability of functioning free muscle transfer and vascularized ulnar nerve grafting for elbow flexion in complete brachial plexus palsy. J Hand Surg Eur Vol 2017; 42:693-699. [PMID: 28387564 DOI: 10.1177/1753193417702029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We compared outcomes of primary vascularized ulnar nerve grafts from the C5 root neurotizing biceps and brachialis muscles, and gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve, as a primary or salvage procedure after complete brachial plexus injury. At 45 months, three of eight primary vascularized ulnar nerve graft patients regained grade 4 elbow flexion, while one regained grade 3. All 13 primary gracilis transfer patients regained grade 4 elbow flexion. Four patients with vascularized ulnar nerve grafts failed and subsequently had salvage functioning free muscle transfer procedures resulting in delayed recovery. Although vascularized ulnar nerve graft-based primary reconstructions can provide useful elbow flexion, this was achieved in less than half the cases. We consider primary gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve as the most reliable reconstruction for the restoration of elbow flexion in complete brachial plexus injury. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- S M Potter
- 1 Victorian Plastic Surgery Unit, St Vincent's Private Hospital, East Melbourne, Victoria, Australia.,2 Department of Plastic, Hand and Faciomaxillary Surgery, The Alfred Hospital, Prahan, Victoria, Australia
| | - S I Ferris
- 1 Victorian Plastic Surgery Unit, St Vincent's Private Hospital, East Melbourne, Victoria, Australia.,2 Department of Plastic, Hand and Faciomaxillary Surgery, The Alfred Hospital, Prahan, Victoria, Australia
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Bertelli JA, Ghizoni MF. Nerve transfers for restoration of finger flexion in patients with tetraplegia. J Neurosurg Spine 2016; 26:55-61. [PMID: 27494781 DOI: 10.3171/2016.5.spine151544] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this paper was to report the authors' results with finger flexion restoration by nerve transfer in patients with tetraplegia. METHODS Surgery was performed for restoration of finger flexion in 17 upper limbs of 9 patients (8 male and 1 female) at a mean of 7.6 months (SD 4 months) after cervical spinal cord injury. The patients' mean age at the time of surgery was 28 years (SD 15 years). The motor level according to the ASIA (American Spinal Injury Association) classification was C-5 in 4 upper limbs, C-6 in 10, and C-7 in 3. In 3 upper limbs, the nerve to the brachialis was transferred to the anterior interosseous nerve (AIN), which was separated from the median nerve from the antecubital fossa to the midarm. In 5 upper limbs, the nerve to the brachialis was transferred to median nerve motor fascicles innervating finger flexion muscles in the midarm. In 4 upper limbs, the nerve to the brachioradialis was transferred to the AIN. In the remaining 5 upper limbs, the nerve to the extensor carpi radialis brevis (ECRB) was transferred to the AIN. Patients were followed for an average of 16 months (SD 6 months). At the final evaluation the range of finger flexion and strength were estimated by manual muscle testing according to the British Medical Research Council scale. RESULTS Restoration of finger flexion was observed in 4 of 8 upper limbs in which the nerve to the brachialis was used as a donor. The range of motion was incomplete in all 5 of these limbs, and the strength was M3 in 3 limbs and M4 in 1 limb. Proximal retrograde dissection of the AIN was associated with better outcomes than transfer of the nerve to the brachialis to median nerve motor fascicles in the arm. After the nerve to the brachioradialis was transferred to the AIN, incomplete finger flexion with M4 strength was restored in 1 limb; the remaining 3 limbs did not show any recovery. Full finger flexion with M4 strength was demonstrated in all 5 upper limbs in which the nerve to the ECRB was transferred to the AIN. No functional downgrading of elbow flexion or wrist extension strength was observed. CONCLUSIONS In patients with tetraplegia, finger flexion can be restored by nerve transfer. Nerve transfer using the nerve to the ECRB as the donor nerve produced better recovery of finger flexion in comparison with nerve transfer using the nerve to the brachialis or brachioradialis.
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Affiliation(s)
- Jayme A Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão; and.,Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Marcos F Ghizoni
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
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Bittner GD, Sengelaub DR, Trevino RC, Peduzzi JD, Mikesh M, Ghergherehchi CL, Schallert T, Thayer WP. The curious ability of polyethylene glycol fusion technologies to restore lost behaviors after nerve severance. J Neurosci Res 2015; 94:207-30. [PMID: 26525605 DOI: 10.1002/jnr.23685] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/17/2015] [Accepted: 10/12/2015] [Indexed: 01/09/2023]
Abstract
Traumatic injuries to PNS and CNS axons are not uncommon. Restoration of lost behaviors following severance of mammalian peripheral nerve axons (PNAs) relies on regeneration by slow outgrowths and is typically poor or nonexistent when after ablation or injuries close to the soma. Behavioral recovery after severing spinal tract axons (STAs) is poor because STAs do not naturally regenerate. Current techniques to enhance PNA and/or STA regeneration have had limited success and do not prevent the onset of Wallerian degeneration of severed distal segments. This Review describes the use of a recently developed polyethylene glycol (PEG) fusion technology combining concepts from biochemical engineering, cell biology, and clinical microsurgery. Within minutes after microsuturing carefully trimmed cut ends and applying a well-specified sequence of solutions, PEG-fused axons exhibit morphological continuity (assessed by intra-axonal dye diffusion) and electrophysiological continuity (assessed by conduction of action potentials) across the lesion site. Wallerian degeneration of PEG-fused PNAs is greatly reduced as measured by counts of sensory and/or motor axons and maintenance of axonal diameters and neuromuscular synapses. After PEG-fusion repair, cut-severed, crush-severed, or ablated PNAs or crush-severed STAs rapidly (within days to weeks), more completely, and permanently restore PNA- or STA-mediated behaviors compared with nontreated or conventionally treated animals. PEG-fusion success is enhanced or decreased by applying antioxidants or oxidants, trimming cut ends or stretching axons, and exposure to Ca(2+) -free or Ca(2+) -containing solutions, respectively. PEG-fusion technology employs surgical techniques and chemicals already used by clinicians and has the potential to produce a paradigm shift in the treatment of traumatic injuries to PNAs and STAs.
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Affiliation(s)
- G D Bittner
- Department of Neuroscience, University of Texas at Austin, Austin, Texas
| | - D R Sengelaub
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - R C Trevino
- Department of Orthopedic Surgery, Wellspan Health, York, Pennsylvania
| | - J D Peduzzi
- Department of Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, Michigan
| | - M Mikesh
- Department of Neuroscience, University of Texas at Austin, Austin, Texas
| | - C L Ghergherehchi
- Department of Neuroscience, University of Texas at Austin, Austin, Texas
| | - T Schallert
- Department of Psychology, University of Texas at Austin, Austin, Texas
| | - W P Thayer
- Department of Plastic Surgery, Vanderbilt School of Medicine, Nashville, Tennessee
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Dy CJ, Garg R, Lee SK, Tow P, Mancuso CA, Wolfe SW. A systematic review of outcomes reporting for brachial plexus reconstruction. J Hand Surg Am 2015; 40:308-13. [PMID: 25510158 PMCID: PMC7079817 DOI: 10.1016/j.jhsa.2014.10.033] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 10/14/2014] [Accepted: 10/14/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To better understand the manner in which outcomes are reported after brachial plexus reconstruction, we conducted a systematic review of the scientific literature. METHODS We included English-language articles describing treatment of brachial plexus injuries to restore motor function of the shoulder, elbow, forearm, and/or wrist with nerve repair, nerve graft, and/or nerve transfer. We recorded the anatomical location of injury, the treatment used, and the manner in which motor function, active and passive range of motion, pain, quality of life, function or disability, patient satisfaction, and psychosocial health was reported. RESULTS In reviewing 88 papers with outcomes for 5,189 patients, 83 (94%) of the papers reported postoperative motor function. Of these, 49 (59%) did not include any other measures of patient outcome. Active range of motion was reported in 24 (27%) studies, pain was reported in 15 (17%) studies, quality of life was reported in 4 (5%) studies, function or disability was reported in 5 (6%) studies, patient satisfaction in 3 (3%) studies, and psychosocial health in 1 study. CONCLUSIONS To date, outcome reporting for brachial plexus surgery has largely centered on motor recovery and typically has not included measures of function or nonmusculoskeletal recovery. Incorporating currently used measures of physical recovery with patient-derived outcomes measures such as quality of life, function, pain, and satisfaction will likely help provide a more comprehensive understanding of the effect of brachial plexus reconstruction surgery. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic III.
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Affiliation(s)
- Christopher J. Dy
- Division of Hand and Upper Extremity Surgery, Hospital for
Special Surgery – New York, NY,Division of Hand and Upper Extremity Surgery, Washington
University School of Medicine – St. Louis, MO
| | - Rohit Garg
- Division of Hand and Upper Extremity Surgery, Hospital for
Special Surgery – New York, NY
| | - Steve K. Lee
- Division of Hand and Upper Extremity Surgery, Hospital for
Special Surgery – New York, NY
| | - Phillip Tow
- Division of Hand and Upper Extremity Surgery, Hospital for
Special Surgery – New York, NY
| | | | - Scott W. Wolfe
- Division of Hand and Upper Extremity Surgery, Hospital for
Special Surgery – New York, NY
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15
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Riley DC, Bittner GD, Mikesh M, Cardwell NL, Pollins AC, Ghergherehchi CL, Bhupanapadu Sunkesula SR, Ha TN, Hall BTD, Poon AD, Pyarali M, Boyer RB, Mazal AT, Munoz N, Trevino RC, Schallert T, Thayer WP. Polyethylene glycol-fused allografts produce rapid behavioral recovery after ablation of sciatic nerve segments. J Neurosci Res 2014; 93:572-83. [PMID: 25425242 DOI: 10.1002/jnr.23514] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/19/2014] [Accepted: 10/09/2014] [Indexed: 11/08/2022]
Abstract
Restoration of neuronal functions by outgrowths regenerating at ∼1 mm/day from the proximal stumps of severed peripheral nerves takes many weeks or months, if it occurs at all, especially after ablation of nerve segments. Distal segments of severed axons typically degenerate in 1-3 days. This study shows that Wallerian degeneration can be prevented or retarded, and lost behavioral function can be restored, following ablation of 0.5-1-cm segments of rat sciatic nerves in host animals. This is achieved by using 0.8-1.1-cm microsutured donor allografts treated with bioengineered solutions varying in ionic and polyethylene glycol (PEG) concentrations (modified PEG-fusion procedure), being careful not to stretch any portion of donor or host sciatic nerves. The data show that PEG fusion permanently restores axonal continuity within minutes, as initially assessed by action potential conduction and intracellular diffusion of dye. Behavioral functions mediated by the sciatic nerve are largely restored within 2-4 weeks, as measured by the sciatic functional index. Increased restoration of sciatic behavioral functions after ablating 0.5-1-cm segments is associated with greater numbers of viable myelinated axons within and distal to PEG-fused allografts. Many such viable myelinated axons are almost certainly spared from Wallerian degeneration by PEG fusion. PEG fusion of donor allografts may produce a paradigm shift in the treatment of peripheral nerve injuries.
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Affiliation(s)
- D C Riley
- Department of Plastic Surgery, Vanderbilt School of Medicine, Nashville, Tennessee; Department of Neuroscience, University of Texas at Austin, Austin, Texas
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Yang LJS, Chang KWC, Chung KC. A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury. Neurosurgery 2013; 71:417-29; discussion 429. [PMID: 22811085 DOI: 10.1227/neu.0b013e318257be98] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Nerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion.
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Affiliation(s)
- Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-5338, USA.
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Wehrli L, Bonnard C, Anastakis DJ. Current Status of Brachial Plexus Reconstruction: Restoration of Hand Function. Clin Plast Surg 2011; 38:661-81. [DOI: 10.1016/j.cps.2011.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bertelli JA, Ghizoni MF. Results and current approach for Brachial Plexus reconstruction. J Brachial Plex Peripher Nerve Inj 2011; 6:2. [PMID: 21676269 PMCID: PMC3127738 DOI: 10.1186/1749-7221-6-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 06/16/2011] [Indexed: 12/15/2022] Open
Abstract
We review our experience treating 335 adult patients with supraclavicular brachial plexus injuries over a 7-year period at the University of Southern Santa Catarina, in Brazil. Patients were categorized into 8 groups, according to functional deficits and roots injured: C5-C6, C5-C7, C5-C8 (T1 Hand), C5-T1 (T2 Hand), C8-T1, C7-T1, C6-T1, and total palsy. To restore function, nerve grafts, nerve transfers, and tendon and muscle transfers were employed. Patients with either upper- or lower-type partial injuries experienced considerable functional return. In total palsies, if a root was available for grafting, 90% of patients had elbow flexion restored, whereas this rate dropped to 50% if no roots were grafted and only nerve transfers performed. Pain resolution should be the first priority, and root exploration and grafting helped to decrease or eliminate pain complaints within a short time of surgery.
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Affiliation(s)
- Jayme A Bertelli
- Center of Biological and Health Sciences, University of Southern Santa Catarina (Unisul), Tubarão, SC, Brazil.
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Bertelli JA, Ghizoni MF. Reconstruction of complete palsies of the adult brachial plexus by root grafting using long grafts and nerve transfers to target nerves. J Hand Surg Am 2010; 35:1640-6. [PMID: 20843615 DOI: 10.1016/j.jhsa.2010.06.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 06/10/2010] [Accepted: 06/14/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE We report on the results we obtained with reconstruction for total paralysis of the brachial plexus using long nerve grafts that connect nonavulsed roots to the musculocutaneous and radial nerve. Nerve transfers were performed to restore function of the suprascapular nerve, triceps long head, and pectoralis major muscle. METHODS We studied 22 young adults with complete brachial plexus palsy who had surgical repair an average of 5 months after trauma. Nerve grafts connected the C5 root to the musculocutaneous nerve. The C6 root was connected by grafts to the radial nerve. When the C6 root was avulsed, the levator scapulae motor branch was connected by grafts to the triceps long head motor branch. In 13 patients, the platysma motor branch was transferred to the medial pectoralis nerve through a long nerve graft. The suprascapular nerve was repaired through transfer of the accessory nerve. Outcomes were assessed an average of 27 months after surgery, focusing on recovery of muscle strength, categorized using the Medical Research Council scale. RESULTS All but one patient recovered some shoulder abduction, with a mean range of recovered shoulder abduction of 57°. Pectoralis major reinnervation was observed in 9 of the 13. Twenty patients recovered full elbow flexion and achieved at least grade M3 strength. Among the 10 patients in whom the C6 root was grafted to the radial nerve, 4 patients recovered active elbow extension with biceps co-contraction. All patients in whom the levator scapulae nerve was connected to the triceps long head recovered active elbow extension, albeit weak. Double lesions of the musculocutaneous nerve were identified in 4 patients. CONCLUSIONS Accessory to suprascapular nerve transfer, levator scapulae nerve transfer to the triceps long head and C5 root grafting to the musculocutaneous nerve is now our preferred method of reconstruction in total palsies of the brachial plexus. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jayme Augusto Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Brazil.
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