1
|
Cavalheiro CS, Nakamoto JC, Wei TH, Sorrenti L, Wataya EY. Histological Compatibility in Distal Neurotizations: A Systematic Review. Indian J Plast Surg 2023; 56:405-412. [PMID: 38026776 PMCID: PMC10663082 DOI: 10.1055/s-0043-1774385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Considering the importance of defining the minimum number of axons between recipient and donor branches, that is, the definition of histological compatibility in distal neurotizations for the success of the procedure and the surgeon's freedom to choose individualized strategies for each patient, this systematic review was conducted to find out the most recent studies on the subject. The objective of this systematic review was to determine the importance of the number of axons and the relationship between axon counts in the donor and recipient nerves in the success of nerve transfer. A literature review was performed on five international databases: Web of Science, Scopus, Wiley (Cochrane Database), Embase, and PubMed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed (2020 version), a guide designed to guide the elaboration of systematic literature reviews. One hundred and fifty-seven studies were found, and 23 were selected based on the eligibility criteria. The articles presented were conclusive in determining the importance of the number of axons in the success of nerve transfer. Still, the relationship between the number of axons in the donor and recipient nerves seems more relevant in the success of transfers and is not always explored by the authors. The review of the articles has provided compelling evidence that the number of axons is a critical determinant of the success of nerve transfer procedures. However, the relationship between the number of axons in the donor nerve and that in the recipient nerve appears to be even more crucial for successful transfers, a factor that is not always adequately explored by authors in the existing literature. Level of evidence : Level IV, therapeutic study.
Collapse
Affiliation(s)
- Cristina Schmitt Cavalheiro
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
- Institute of Orthopedic and Traumatology, Faculdade de Medicina, Universidade de Sâo Paulo, São Paulo, SP, Brazil
| | - João Carlos Nakamoto
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
| | - Teng Hsiang Wei
- Institute of Orthopedic and Traumatology, Faculdade de Medicina, Universidade de Sâo Paulo, São Paulo, SP, Brazil
| | - Luiz Sorrenti
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
| | - Erick Yoshio Wataya
- Department of Hand, Wrist and Microsurgery, Instituto Vita, São Paulo, SP, Brazil
| |
Collapse
|
2
|
Chim H. Reconstruction of Prehension in C7-T1 Brachial Plexus Injury with Nerve and Tendon Transfers: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00050. [PMID: 37590889 DOI: 10.2106/jbjs.cc.22.00798] [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: 08/19/2023]
Abstract
CASE Reconstruction of function in C7-T1 lower brachial plexus injury requires restoration of finger flexion and extension with nerve or tendon transfers. A 22-year-old man was involved in an all-terrain vehicle rollover accident. First-stage nerve transfers included extensor carpi radialis brevis to the anterior interosseous nerve and supinator to the posterior interosseous nerve. After second-stage (15 months later) side-to-side flexor digitorum profundus and Camitz abductorplasty, he was able to achieve tripod pinch and power grip. CONCLUSION A combined approach with nerve transfers followed by tendon transfers allows restoration of prehension in lower BPI while preserving the brachialis as a backup donor.
Collapse
Affiliation(s)
- Harvey Chim
- Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine, Gainesville, Florida
| |
Collapse
|
3
|
Francoisse CA, Russo SA, Skladman R, Kahn LC, Kennedy C, Stenson KC, Novak CB, Fox IK. Quantifying Donor Deficits Following Nerve Transfer Surgery in Tetraplegia. J Hand Surg Am 2022; 47:1157-1165. [PMID: 36257880 DOI: 10.1016/j.jhsa.2022.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/09/2022] [Accepted: 08/11/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE Nerve transfer (NT) surgery can improve function in people with cervical spinal cord injury (SCI). However, the impact of donor nerve deficits remains unclear. The purpose of this study was to quantify donor deficits experienced by individuals with cervical SCI following NT. METHODS This prospective single-arm, comparative study included people with SCI undergoing upper extremity NTs. Myometry was used to assess muscle strength at baseline and follow-up. The Spinal Cord Independence Measure was used to measure the ability to perform activities of daily living. RESULTS Ten individuals underwent 20 NTs to restore elbow extension (donor, posterior deltoid; n = 2), hand opening (donor, supinator; n = 7), and hand closing (donor, brachialis; n = 11). Shoulder abduction strength decreased (-5.6% at early and -4.5% late follow-up) in the elbow extension NT. Wrist extension strength decreased at early (-46.9% ± 30.3) and increased by late (76.4% ± 154.0) follow-up in the hand opening NT. No statistically significant change in elbow flexion strength was noted in the hand closing NT. Spinal Cord Independence Measure scores did not change significantly between baseline and early postoperative follow-up; they improved at late follow-up. CONCLUSIONS Use of expendable donor nerves with redundant function to perform NT surgery has relatively little impact on strength or capacity to perform activities of daily living, even in the unique and highly vulnerable SCI population. Early, temporary loss in wrist extension strength can be seen after the supinator to posterior interosseous nerve transfer. This study offers quantitative data about possible diminution of donor function after NT, enabling hand surgeons to better counsel individuals contemplating upper extremity reconstruction. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic I.
Collapse
Affiliation(s)
- Caitlin A Francoisse
- Division of Plastic Surgery, St. Louis University School of Medicine, St. Louis, MO
| | - Stephanie A Russo
- Department of Orthopedic Surgery, Akron Children's Hospital, Akron, OH
| | - Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO
| | - Lorna C Kahn
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO
| | - Carie Kennedy
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, MO
| | | | - Christine B Novak
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ida K Fox
- VA St. Louis Healthcare System, St. Louis, MO.
| |
Collapse
|
4
|
Ziaziaris WA, Ahadi MS, Gill AJ, Ledgard JP. The Anatomy of Nerve Transfers Used in Tetraplegic Hand Reconstruction. J Hand Surg Am 2022; 47:1121.e1-1121.e6. [PMID: 34702629 DOI: 10.1016/j.jhsa.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/05/2021] [Accepted: 09/03/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the anatomy of nerve transfers used to reconstruct wrist extension, hand opening, and hand closing in tetraplegic patients. METHODS Nerve transfers were completed on 18 paired cadaveric upper limbs. The overlap of donor and recipient nerves was measured, as well as the distance to the target muscle. Axons were counted in each nerve and branch, with the axon percentage calculated by dividing the donor nerve count by that of the recipient. RESULTS Transfers with overlap of the donor and recipient nerve were from the radial nerve branch to extensor carpi radialis brevis to anterior interosseous nerve (AIN) and from the branch(es) to supinator to posterior interosseous nerve. The extensor carpi radialis brevis to AIN had the shortest distance to the target, with the branch to brachialis to AIN being the longest. The nerve transfers for wrist extension had the highest axon percentage. Of the transfers for hand closing, the brachialis to AIN had the highest axon percentage, and the branch to brachioradialis to AIN had the lowest. CONCLUSIONS The anatomical features of nerve transfers used in tetraplegic hand reconstruction are variable. Differences may help explain clinical outcomes. CLINICAL RELEVANCE This study demonstrates which nerve transfers may be anatomically favorable for restoring hand function in tetraplegic patients.
Collapse
Affiliation(s)
- William A Ziaziaris
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mahsa S Ahadi
- University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Anthony J Gill
- University of Sydney, Sydney, New South Wales, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - James P Ledgard
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.
| |
Collapse
|
5
|
Jitpun E, Rojanawatsirivej A, Tangviriyapaiboon T. Single-stage double motor nerve transfer for all finger flexion in iatrogenic C8-T1 spinal nerve injury: a case report and review of literature. Acta Neurochir (Wien) 2022; 164:2683-2688. [PMID: 35660975 DOI: 10.1007/s00701-022-05264-0] [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: 01/31/2022] [Accepted: 05/16/2022] [Indexed: 01/26/2023]
Abstract
Restoration of hand function after C8-T1 spinal nerve injury is challenging. We report a case of a young patient who underwent single-stage transfer of extensor carpi radialis brevis (ECRB) branch of radial nerve to flexor digitorum superficialis (FDS) branch of median nerve and transfer of brachialis branch of musculocutaneous nerve to anterior interosseous nerve (AIN), aiming for restoration of all finger flexion in iatrogenic C8-T1 spinal nerve injury after the resection of a dumbbell-shaped C8 neurofibroma. At 18 months after the operation, the fingers and thumb functions were successfully restored. The operation might be useful for restoration of hand function in selected patients with C8, T1 brachial plexus injury. From the literature review, this is the first case that the technique of double motor nerve transfer and the transfer of ECRB branch to FDS branch were used to restore finger flexion in a patient with brachial plexus injury.
Collapse
Affiliation(s)
- Ekkapot Jitpun
- Department of Neurosurgery, Neurological Institute of Thailand, 312, Rajavithi Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand.
| | | | - Teera Tangviriyapaiboon
- Department of Neurosurgery, Neurological Institute of Thailand, 312, Rajavithi Road, Thung Phayathai, Ratchathewi, Bangkok, Thailand
| |
Collapse
|
6
|
Silverman J, Dengler J, Song C, Robinson LR. Pre-operative electrodiagnostic planning for upper limb peripheral nerve transfers in cervical spinal cord injury: A Narrative Review. PM R 2022. [PMID: 35726540 DOI: 10.1002/pmrj.12868] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 02/13/2022] [Accepted: 05/31/2022] [Indexed: 11/08/2022]
Abstract
Peripheral nerve transfer (PNT) to improve upper limb function following cervical spinal cord injury (SCI) involves the transfer of supralesional donor nerves under voluntary control to intralesional or sublesional lower motor neurons not under voluntary control. Appropriate selection of donor and recipient nerves and surgical timing impact functional outcomes. While the gold standard of nerve selection is intra-operative nerve stimulation, preoperative electrodiagnostic (EDX) evaluation may help guide surgical planning. Currently there is no standardized preoperative EDX protocol. This study reviews the EDX workup preceding peripheral nerve transfer surgery in cervical SCI, and proposes an informed EDX protocol to assist with surgical planning. The PICO (Population, Intervention, Comparison, Outcome) framework was used to formulate relevant MeSH terms and identify published cases of PNT in cervical SCI in Medline, Embase, CINAHL, and Emcare databases in the last 10 years. The electrodiagnostic techniques evaluating putative donor nerves, recipient nerve branches, time-sensitivity of nerve transfer and other electrophysiological parameters were summarized to guide creation of a preoperative EDX protocol. Needle electromyography (EMG) was the most commonly used EDX technique to identify healthy donor nerves. Although needle EMG has also been used on recipient nerves, compound muscle action potential (CMAP) amplitudes may provide a more accurate determination of recipient nerve health and time-sensitivity for nerve transfer. While there has been progress in pre-surgical EDX evaluation, EMG and NCS approaches are quite variable, and each has limitations in their utility for pre-operative planning. There is need for standardization in the EDX evaluation preceding peripheral nerve transfer surgery to assist with donor and recipient nerve selection, surgical timing and to optimize outcomes. Based on results of this review, herein we propose the PreSCIse (PRotocol for Electrodiagnosis in SCI Surgery of the upper Extremity) pre-operative EDX panel to achieve said goals through an interdisciplinary and patient-centered approach. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Jordan Silverman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jana Dengler
- Division of Plastic and Reconstructive Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Cimon Song
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence R Robinson
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Waris E, Palmgren-Soppela T, Sommarhem A. Nerve Transfer of Brachialis Branch to Anterior Interosseus Nerve Using In Situ Lateral Antebrachial Cutaneous Nerve Graft in Tetraplegia. J Hand Surg Am 2022; 47:390.e1-390.e7. [PMID: 34217555 DOI: 10.1016/j.jhsa.2021.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 02/21/2021] [Accepted: 04/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Reconstruction of finger motion is a therapeutic goal in tetraplegic patients. Although nerve transfer of the brachialis branch of the musculocutaneous nerve to the anterior interosseus nerve has been previously described, this results in unreliable reinnervation because the donor nerve is proximal to the target muscle. We describe an alternative technique in which nerve transfer is performed using the lateral antebrachial cutaneous nerve as a vascular in situ nerve graft. The clinical results are reported. METHODS Nine upper limbs of 6 patients (mean age 25 years) with tetraplegia were subjected to brachialis-to-anterior interosseus nerve transfer using the lateral antebrachial cutaneous nerve as a vascular in situ nerve graft, at a mean of 6 months after injury. Additional supinator branch transfer to the posterior interosseous nerve was performed for 6 upper limbs and to the flexor digitorum superficialis motor branch for 1 upper limb. RESULTS At a mean of 2 years of follow-up, thumb and finger flexion strength scored M3-M4 in 5 of the 9 limbs according to the Medical Research Council scale. Key pinch and grip pinch averaged 0.6 kg (range, 0-1.0 kg) and 2.2 kg (range, 0-8 kg), respectively. No donor-site deficit was observed. CONCLUSIONS Brachialis-to-anterior interosseus nerve transfer with an in situ lateral antebrachial cutaneous nerve graft can be used to reconstruct thumb and finger flexion in tetraplegic patients. Combined with supinator-to- posterior interosseous nerve transfer, simultaneous active extension of the fingers can be achieved. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
Collapse
Affiliation(s)
- Eero Waris
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Tove Palmgren-Soppela
- Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Sommarhem
- Department of Children's Orthopedics and Traumatology, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
8
|
Plasticity of the Central Nervous System Involving Peripheral Nerve Transfer. Neural Plast 2022; 2022:5345269. [PMID: 35342394 PMCID: PMC8956439 DOI: 10.1155/2022/5345269] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/09/2022] [Accepted: 02/28/2022] [Indexed: 11/22/2022] Open
Abstract
Peripheral nerve injury can lead to partial or complete loss of limb function, and nerve transfer is an effective surgical salvage for patients with these injuries. The inability of deprived cortical regions representing damaged nerves to overcome corresponding maladaptive plasticity after the reinnervation of muscle fibers and sensory receptors is thought to be correlated with lasting and unfavorable functional recovery. However, the concept of central nervous system plasticity is rarely elucidated in classical textbooks involving peripheral nerve injury, let alone peripheral nerve transfer. This article is aimed at providing a comprehensive understanding of central nervous system plasticity involving peripheral nerve injury by reviewing studies mainly in human or nonhuman primate and by highlighting the functional and structural modifications in the central nervous system after peripheral nerve transfer. Hopefully, it will help surgeons perform successful nerve transfer under the guidance of modern concepts in neuroplasticity.
Collapse
|
9
|
Abstract
Nerve transfer surgery has expanded reconstructive options for restoring upper extremity function following spinal cord injury. By adding new motor donors to the pool already available through tendon transfers, the effectiveness of treatment should improve. Planning which procedures and in which order to perform, along with their details must be delineated. To meet these demands, refined diagnostics are needed, along with awareness of the remaining challenges to restore intrinsic muscle function and to address spasticity and its consequences. This article summaries recent advances in surgical reanimation of upper extremity motor control, together with an overview of the development of neuro-prosthetic and neuromodulation techniques to modify recovery or substitute for functional losses after spinal cord injuries.
Collapse
Affiliation(s)
- Jan Fridén
- Department of Tetrahand Surgery, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - James House
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Michael Keith
- Departments of Orthopaedic Surgery, BioMedical Engineering, Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA
| | - Silvia Schibli
- Department of Tetrahand Surgery, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Natasha van Zyl
- Department of Plastic and Reconstructive Surgery, Austin Health, Melbourne, VIC, Australia
| |
Collapse
|
10
|
Qian TD, Zheng XF, Shi J, Ma T, You WY, Wu JH, Huang BS, Tao Y, Wang X, Song ZW, Li LX. L4-to-L4 nerve root transfer for hindlimb hemiplegia after hypertensive intracerebral hemorrhage. Neural Regen Res 2021; 17:1278-1285. [PMID: 34782572 PMCID: PMC8643034 DOI: 10.4103/1673-5374.327359] [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: 11/16/2022] Open
Abstract
There is no effective treatment for hemiplegia after hypertensive intracerebral hemorrhage. Considering that the branches of L4 nerve roots in the lumbar plexus root control the movement of the lower extremity anterior and posterior muscles, we investigated a potential method of nerve repair using the L4 nerve roots. Rat models of hindlimb hemiplegia after a hypertensive intracerebral hemorrhage were established by injecting autogenous blood into the posterior limb of internal capsule. The L4 nerve root on the healthy side of model rats was transferred and then anastomosed with the L4 nerve root on the affected side to drive the extensor and flexor muscles of the hindlimbs. We investigated whether this method can restore the flexible movement of the hindlimbs of paralyzed rats after hypertensive intracerebral hemorrhage. In a beam-walking test and ladder rung walking task, model rats exhibited an initial high number of slips, but improved in accuracy on the paretic side over time. At 17 weeks after surgery, rats gained approximately 58.2% accuracy from baseline performance and performed ankle motions on the paretic side. At 9 weeks after surgery, a retrograde tracing test showed a large number of fluoro-gold-labeled motoneurons in the left anterior horn of the spinal cord that supports the L4-to-L4 nerve roots. In addition, histological and ultramicrostructural findings showed axon regeneration of motoneurons in the anterior horn of the spinal cord. Electromyography and paw print analysis showed that denervated hindlimb muscles regained reliable innervation and walking coordination improved. These findings suggest that the L4-to-L4 nerve root transfer method for the treatment of hindlimb hemiplegia after hypertensive intracerebral hemorrhage can improve the locomotion of hindlimb major joints, particularly of the distal ankle. Findings from study support that the L4-to-L4 nerve root transfer method can effectively repair the hindlimb hemiplegia after hypertensive intracerebral hemorrhage. All animal experiments were approved by the Animal Ethics Committee of the First Affiliated Hospital of Nanjing Medical University (No. IACUC-1906009) in June 2019.
Collapse
Affiliation(s)
- Teng-Da Qian
- Department of Neurosurgery, Jintan Hospital, Affiliated Hospital of Jiangsu Vocational College of Medicine, Jintan, Jiangsu Province, China
| | - Xi-Feng Zheng
- Department of Gastroenterology, Jintan Hospital, Affiliated Hospital of Jiangsu Vocational College of Medicine, Jintan, Jiangsu Province, China
| | - Jing Shi
- Department of Neurosurgery, Changzhou First People's Hospital, Suzhou University, Changzhou, Jiangsu Province, China
| | - Tao Ma
- Department of Neurosurgery, Changzhou First People's Hospital, Suzhou University, Changzhou, Jiangsu Province, China
| | - Wei-Yan You
- Deparment of Neurobiology, Basic Medical College, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jia-Huan Wu
- Deparment of Neurobiology, Basic Medical College, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Bao-Sheng Huang
- Department of Neurosurgery, Sir Run Run Hospital Affiliated to Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yi Tao
- Department of Neurosurgery, Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xi Wang
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ze-Wu Song
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Li-Xin Li
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| |
Collapse
|
11
|
Bertelli JA, Patel N, Soldado F, Duarte ECW. Patterns of median nerve branching in the cubital fossa: implications for nerve transfers to restore motor function in a paralyzed upper limb. J Neurosurg 2021; 135:1524-1533. [PMID: 33740763 DOI: 10.3171/2020.9.jns202742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the anatomy of donor and recipient median nerve motor branches for nerve transfer surgery within the cubital fossa. METHODS Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery. RESULTS In the cubital fossa, the first branch was always the proximal branch of the pronator teres (PPT), whereas the last one was the anterior interosseous nerve (AIN) and the distal motor branch of the flexor digitorum superficialis (DFDS) on a consistent basis. The PT muscle was also innervated by a distal branch (DPT), which emerged from the anterior side of the median nerve and provided innervation to its deep head. The palmaris longus (PL) motor branch was always the second branch after the PPT, emerging as a single branch together with the flexor carpi radialis (FCR) or the proximal branch of the flexor digitorum superficialis. The FCR motor branch was prone to variations. It originated proximally with the PL branch (35%) or distally with the AIN (35%), and less frequently from the DPT. In 40% of dissections, the FDS was innervated by a single branch (i.e., the DFDS) originating close to the AIN. In 60% of cases, a proximal branch originated together with the PL or FCR. The AIN emerged from the posterior side of the median nerve and had a diameter of 2.3 mm, twice that of other branches. When dissections were performed between the PT and FCR muscles at the FDS arcade, we observed the AIN lying lateral and the DFDS medial to the median nerve. After crossing the FDS arcade, the AIN divided into: 1) a lateral branch to the flexor pollicis longus (FPL), which bifurcated to reach the anterior and posterior surfaces of the FPL; 2) a medial branch, which bifurcated to reach the flexor digitorum profundus (FDP); and 3) a long middle branch to the pronator quadratus. The average numbers of myelinated fibers within each median nerve branch were as follows (values expressed as the mean ± SD): PPT 646 ± 249; DPT 599 ± 150; PL 259 ± 105; FCR 541 ± 199; proximal FDS 435 ± 158; DFDS 376 ± 150; FPL 480 ± 309; first branch to the FDP 397 ± 12; and second branch to the FDP 369 ± 33. CONCLUSIONS The median nerve's branching pattern in the cubital fossa is predictable. The most important variation involves the FCR motor branch. These anatomical findings aid during nerve transfer surgery to restore function when paralysis results from injury to the radial or median nerves, brachial plexus, or spinal cord.
Collapse
Affiliation(s)
- Jayme A Bertelli
- 1Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil
- 2Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Neehar Patel
- 3Department of Plastic Surgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Francisco Soldado
- 4Pediatric Hand Surgery and Microsurgery Unit, Barcelona University Children's Hospital HM Nens, HM Hospitales, Barcelona, Spain
- 5Pediatric Hand Surgery and Microsurgery Unit, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; and
| | | |
Collapse
|
12
|
van Zyl N, Galea MP, Cooper C, Hahn J, Hill B. Transfer of the supinator nerve to the posterior interosseous nerve for hand opening in tetraplegia through an anterior approach. J Hand Surg Eur Vol 2021; 46:717-724. [PMID: 33673745 DOI: 10.1177/1753193421996987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report a retrospective series of 44 transfers in 26 patients in whom a functioning supinator nerve was transferred to a paralyzed posterior interosseous nerve through a single, anterior approach to re-animate hand opening in mid-cervical tetraplegia. Eighteen patients underwent concurrent nerve or tendon transfers to re-animate grasp and/or pinch through the same anterior incision. We evaluated the strength of the innervated muscle at mean follow-up of 24 months (range 12-27). The strength attained in our patients was equivalent to the strength after the transfer through a posterior approach reported in the literature. Nineteen of our patients were satisfied with the hand opening procedure. First webspace opening was the only variable to correlate with patient satisfaction. We conclude that the anterior approach yields similar results to the posterior approach and has the advantage of allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch.Level of evidence: IV.
Collapse
Affiliation(s)
- Natasha van Zyl
- Department of Plastic and Reconstructive Surgery, Austin Health, Heidelberg, VIC, Australia
| | - Mary P Galea
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC, Australia.,Victorian Spinal Cord Service, Austin Health, Heidelberg, VIC, Australia
| | - Catherine Cooper
- Department of Occupational Therapy, Austin Health, Heidelberg, VIC, Australia
| | - Jodie Hahn
- Department of Occupational Therapy, Austin Health, Heidelberg, VIC, Australia
| | - Bridget Hill
- Department of Plastic and Reconstructive Surgery, Austin Health, Heidelberg, VIC, Australia.,Department of Occupational Therapy, Austin Health, Heidelberg, VIC, Australia.,Epworth Monash Rehabilitation Medicine Unit, Epworth HealthCare, Richmond, VIC, Australia
| |
Collapse
|
13
|
Tian J, Wang K, Chen Z, Huang Q. Lateral Antebrachial Cutaneous Nerve as In Situ Nerve Graft in Lower Brachial Plexus Injury. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02910-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
|
14
|
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.
Collapse
|
15
|
Emamhadi M, Haghani Dogahe M, Gohritz A. Nerve transfers in tetraplegia: a review and practical guide. J Neurosurg Sci 2021; 65:431-441. [PMID: 33870671 DOI: 10.23736/s0390-5616.21.05312-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Spinal cord injury (SCI) may lead to tetraplegia. Several nerve transfers have been successfully used for the restoration of the upper limb in tetraplegia. Reconstruction of an upper limb is individualized based on the functional level. In this study, the authors reviewed nerve transfers based on the injury level for the restoration of upper limb function in tetraplegia. EVIDENCE ACQUISITION We performed this study to review nerve transfers in tetraplegia by searching MEDLINE and EMBASE databases to identify relevant articles published through December 2020. We selected studies that reported cases in tetraplegia and extracted information on demographic data, clinical characteristics, operative details, and strength outcomes based on each injury level after surgery. EVIDENCE SYNTHESIS Total of 29 journal articles reporting on 275 nerve transfers in 172 upper limbs of 121 patients were included in the review. The mean time between SCI and nerve transfer surgery was 21.37 months (range: 4-156 months), and the follow-up time was 21.34 months (range: 3-38 months). The best outcomes were achieved for the restoration of wrist/finger extension and elbow extension. CONCLUSIONS Nerve transfer can provide a new function in tetraplegic patients' upper limbs to improve daily living activities. The type of surgical procedure should be performed based on the functional level of SCI and the individual's needs. Functional recovery occurs more in extensor muscles than flexors. Nerve transfer is a promising option in the reconstruction of upper limb function in tetraplegia.
Collapse
Affiliation(s)
- Mohammadreza Emamhadi
- Brachial Plexus and Peripheral Nerve Injury Center, Department of Neurosurgery, Guilan University of Medical Sciences, Rasht, Iran -
| | - Mohammad Haghani Dogahe
- Brachial Plexus and Peripheral Nerve Injury Center, Department of Neurosurgery, Guilan University of Medical Sciences, Rasht, Iran
| | - Andreas Gohritz
- Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
16
|
Niempoog S, Witoonchart K, Jaroenporn W. Hand Surgery in Thailand. J Hand Microsurg 2021; 13:35-41. [PMID: 33707921 DOI: 10.1055/s-0040-1721900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Modern hand surgery in Thailand started after the end of World War II. It is divided into 4 phases. In the initial phase (1950-1965), the surgery of the hand was mainly performed by general surgeons. In 1965-1975, which was the second phase, many plastic surgeons and orthopaedic surgeons graduated from foreign countries and came back to Thailand. They played a vital role in the treatment of the surgery of the hand and set up hand units in many centers. They also contributed to the establishment of the "Thai Society for Surgery of the Hand," which still continues to operate. In the third phase (1975-2000), there was a dramatic development of microsurgery because of the rapid economic expansion. There were many replantation, free tissue transfers, and brachial plexus surgeries in traffic and factory-related accidents. The first hand-fellow training program began in 1993. In the fourth phase (since 2000), the number of hand injuries from factory-related accidents began declining. But the injury from traffic accidents had been increasing both in severity and number. Moreover, the diseases of hand that relate to aging and degeneration had been on the rise. Thai hand surgeons have been using several state-of-the-art technologies such as arthroscopic and endoscopic surgery. They are continuing to invent innovations, generating international publications, and frequently being invited as speakers in foreign countries.
Collapse
Affiliation(s)
- Sunyarn Niempoog
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | | | | |
Collapse
|
17
|
Korotchenko EN, Semenova ZB. [Selective neurotization of the median nerve in young patients with CV-CVIIcomplicated spinal cord injury]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:59-66. [PMID: 33306300 DOI: 10.17116/neiro20208406159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complicated spinal cord injury occurs in 1-5 cases per 100.000. In children, cervical trauma makes up 72% of all spinal trauma. Spinal cord injury complicates vertebral trauma in 25-50% of cases that usually results severe disability. Rehabilitation of these patients is usually ineffective or results a little improvement. Restoration of even minimal movements is essential in these patients. There are reports devoted to surgical rehabilitation of important hand functions after cervical spinal cord injury. OBJECTIVE To demonstrate the restoration of key hand functions in patients with CV-CVII complicated spinal cord injury using selective neurotization of the median nerve. MATERIAL AND METHODS Three patients aged 17-19 years with complicated CV-CVII spinal cord injury and ASIA class A have been selected for surgery for 2 years. Mean period after rehabilitation was 11.3 months. Prior to surgery, all patients recovered flexion/extension in the elbow joints, forearm rotation, flexion and extension of hands. However, there were no active movements in distal phalanges of the fingers, and initial signs of flexor contracture were observed. RESULTS Surgical strategy included selective neurotization of the median nerve with a motor branch of musculocutaneous nerve. In one case, we used additional neurotization of posterior interosseous nerve. Two patients recovered cylindrical grip up to M4 and pinch grip up to M3 within 15 months. In the third patient, postoperative data were not assessed due to short-term follow-up. CONCLUSION Selective neurotization of anterior interosseous nerve may be considered as a stage or independent surgery for restoration of key hand functions. This approach improves the quality of life in patients with complicated spinal cord injury.
Collapse
Affiliation(s)
- E N Korotchenko
- Research Institute of Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| | - Zh B Semenova
- Research Institute of Emergency Pediatric Surgery and Traumatology, Moscow, Russia
| |
Collapse
|
18
|
Ledgard JP, Gschwind CR. Evidence for efficacy of new developments in reconstructive upper limb surgery for tetraplegia. J Hand Surg Eur Vol 2020; 45:43-50. [PMID: 31735097 DOI: 10.1177/1753193419886443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Nerve transfers are increasingly utilized for upper limb reconstruction in tetraplegia. We reviewed the literature for results achieved by nerve transfers for elbow extension, wrist control and finger and thumb flexion and extension. Muscle strength grading was the only outcome measure consistently reported. The results confirm that nerve transfers can effectively reanimate muscles in selected cases, with comparable strength with those achieved with tendon transfer for elbow extension but inferior strength for finger and thumb flexion. Transfer of supinator nerve branches to the posterior interosseous nerve appears to be reliable and offers increased span and better hand opening than is observed after tendon transfers. Only one publication demonstrated how reinnervation of muscles with nerve transfers translated into improved function, activity and participation for patients. More prospective studies, using standardized outcome measures, are needed to define the precise role of nerve transfers.
Collapse
Affiliation(s)
- James P Ledgard
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Claudia R Gschwind
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| |
Collapse
|
19
|
Khalifeh JM, Dibble CF, Van Voorhis A, Doering M, Boyer MI, Mahan MA, Wilson TJ, Midha R, Yang LJS, Ray WZ. Nerve transfers in the upper extremity following cervical spinal cord injury. Part 1: Systematic review of the literature. J Neurosurg Spine 2019; 31:629-640. [PMID: 31299644 DOI: 10.3171/2019.4.spine19173] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/19/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia. METHODS A systematic literature search was conducted using Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed. RESULTS Twenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months-13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month-4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension. CONCLUSIONS Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.
Collapse
Affiliation(s)
| | | | - Anna Van Voorhis
- 2Milliken Hand Rehabilitation Center, Program in Occupational Therapy
| | | | - Martin I Boyer
- 4Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Mahan
- 5Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Thomas J Wilson
- 6Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California
| | - Rajiv Midha
- 7Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; and
| | - Lynda J S Yang
- 8Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | | |
Collapse
|
20
|
Khalifeh JM, Dibble CF, Van Voorhis A, Doering M, Boyer MI, Mahan MA, Wilson TJ, Midha R, Yang LJS, Ray WZ. Nerve transfers in the upper extremity following cervical spinal cord injury. Part 2: Preliminary results of a prospective clinical trial. J Neurosurg Spine 2019; 31:641-653. [PMID: 31299645 DOI: 10.3171/2019.4.spine19399] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/19/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly used to treat patients with cervical SCIs. In this article, the authors present early results of a prospective clinical trial using nerve transfers to restore upper-extremity function in tetraplegia. METHODS Participants with American Spinal Injury Association (ASIA) grade A-C cervical SCI/tetraplegia were prospectively enrolled at a single institution, and nerve transfer(s) was performed to improve upper-extremity function. Functional recovery and strength outcomes were independently assessed and prospectively tracked. RESULTS Seventeen participants (94.1% males) with a median age of 28.4 years (range 18.2-76.3 years) who underwent nerve transfers at a median of 18.2 months (range 5.2-130.8 months) after injury were included in the analysis. Preoperative SCI levels ranged from C2 to C7, most commonly at C4 (35.3%). The median postoperative follow-up duration was 24.9 months (range 12.0-29.1 months). Patients who underwent transfers to median nerve motor branches and completed 18- and 24-month follow-ups achieved finger flexion strength Medical Research Council (MRC) grade ≥ 3/5 in 4 of 15 (26.7%) and 3 of 12 (25.0%) treated upper limbs, respectively. Similarly, patients achieved MRC grade ≥ 3/5 wrist flexion strength in 5 of 15 (33.3%) and 3 of 12 (25.0%) upper limbs. Among patients who underwent transfers to the posterior interosseous nerve (PIN) for wrist/finger extension, MRC grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) upper limbs 18 and 24 months postoperatively, respectively. Similarly, grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) cases for thumb extension. No meaningful donor site deficits were observed. Patients reported significant postoperative improvements from baseline on upper-extremity-specific self-reported outcome measures. CONCLUSIONS Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. In the authors' experience, nerve transfers for the reinnervation of hand and finger flexors showed variable functional recovery; however, transfers for the reinnervation of arm, hand, and finger extensors showed a more consistent and meaningful return of strength and function.
Collapse
Affiliation(s)
| | | | - Anna Van Voorhis
- 2Milliken Hand Rehabilitation Center, Program in Occupational Therapy
| | | | - Martin I Boyer
- 4Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Mahan
- 5Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Thomas J Wilson
- 6Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California
| | - Rajiv Midha
- 7Department of Clinical Neurosciences, University of Calgary, Alberta, Canada; and
| | - Lynda J S Yang
- 8Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | | |
Collapse
|
21
|
Dibble CF, Khalifeh JM, VanVoorhis A, Rich JT, Ray WZ. Novel Nerve Transfers for Motor and Sensory Restoration in High Cervical Spinal Cord Injury. World Neurosurg 2019; 128:611-615.e1. [DOI: 10.1016/j.wneu.2019.04.264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
|