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Clinical application of diffusion tensor tractography to postoperative C5 palsy. Spinal Cord Ser Cases 2021; 7:83. [PMID: 34552046 DOI: 10.1038/s41394-021-00447-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/06/2021] [Accepted: 09/12/2021] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN Diagnostic study. OBJECTIVE Although C5 palsy is a well-known potential complication after cervical procedure, the exact pathophysiology remains uncertain. Diffusion tensor tractography (DTT) has recently been proposed as a useful tool to examine quantitatively and non-invasively the pathology of spinal cord disorders. The purpose of this study is to determine the clinical interest of DTT in patients with C5 palsy after cervical laminoplasty. SETTING Single university hospital. METHODS Five patients with C5 palsy out of 108 patients after cervical laminoplasty were subjected to DTT using a 1.5 Tesla magnetic resonance imaging in our hospital between 2010 and 2012. For the tractography, two regions of interest (ROI) were placed at the C5 segmental level and the bilateral C4/5 intervertebral foramen level. RESULTS The postoperative number of tract fibers at the C5 segmental spinal cord level was significantly increased compared to the preoperative number, despite the C5 palsy. Analyses of two ROIs (at the C5 segmental level and the C4/5 intervertebral foramen level) showed that the number of tract fibers at the palsy side was significantly decreased compared to the intact side. Furthermore, in the patient who spontaneously recovered from C5 palsy within postoperative 6 months, a gradual augmentation of tract fibers was identified at the palsy side. CONCLUSIONS Our findings suggest that DTT can document C5 palsy in detail, as the anatomical region between C5 segmental level and C4/5 intervertebral foramen level was potentially damaged in patients with C5 palsy after laminoplasty.
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Singh S, Das KK, Deora H, Jaiswal AK, Behari S. Traumatic Partial Posterior Cord Brachial Plexus Injury in a Patient with Aberrant Innervation of the Long Head of the Triceps by the Axillary Nerve: Implications in Nerve Transfer Surgery. Asian J Neurosurg 2020; 15:391-393. [PMID: 32656138 PMCID: PMC7335135 DOI: 10.4103/ajns.ajns_160_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 01/21/2020] [Indexed: 11/10/2022] Open
Abstract
Brachial plexus repair forms an unmet need in terms of posttraumatic rehabilitation, especially the young population, wherein the incidence of accidents is high. This leads to decrease in the number of functionally active years after the accident. We encountered an interesting case of posttraumatic posterior cord injury predominantly affecting the shoulder abduction beyond 15°. An electrodiagnostic study showed a complete lack of conduction within the axillary nerve with reduced conduction velocity in the radial nerve. We took the patient up for the long head of the triceps transfer to the anterior division of the axillary nerve transfer. Intraoperatively, we found that the long head branch was originating from the axillary nerve at the point of division. As it could not be used for neurotization, we transferred the medial head branch of the radial nerve to the axillary nerve. The patient started to show electroclinical improvement after 3 months of the surgery. A few similar cases have been published, as a cadaveric finding. We report this case to highlight the possibility and need for a high clinical suspicion and also to provide a possible treatment option, in such aberrant anatomy.
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Affiliation(s)
- Suyash Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Harsh Deora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh Kumar Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Hruby LA, Gstoettner C, Sturma A, Salminger S, Mayer JA, Aszmann OC. Bionic Upper Limb Reconstruction: A Valuable Alternative in Global Brachial Plexus Avulsion Injuries-A Case Series. J Clin Med 2019; 9:jcm9010023. [PMID: 31861941 PMCID: PMC7019829 DOI: 10.3390/jcm9010023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/15/2022] Open
Abstract
Global brachial plexopathies including multiple nerve root avulsions may result in complete upper limb paralysis despite surgical treatment. Bionic reconstruction, which includes the elective amputation of the functionless hand and its replacement with a mechatronic device, has been described for the transradial level. Here, we present for the first time that patients with global brachial plexus avulsion injuries and lack of biological shoulder and elbow function benefit from above-elbow amputation and prosthetic rehabilitation. Between 2012 and 2017, forty-five patients with global brachial plexus injuries approached our centre, of which nineteen (42.2%) were treated with bionic reconstruction. While fourteen patients were amputated at the transradial level, the entire upper limb was replaced with a prosthetic arm in a total of five patients. Global upper extremity function before and after bionic arm substitution was assessed using two objective hand function tests, the action research arm test (ARAT), and the Southampton hand assessment procedure (SHAP). Other outcome measures included the DASH questionnaire, VAS to assess deafferentation pain and the SF-36 health survey to evaluate changes in quality of life. Using a hybrid prosthetic arm mean ARAT scores improved from 0.6 ± 1.3 to 11.0 ± 6.7 (p = 0.042) and mean SHAP scores increased from 4.0 ± 3.7 to 13.8 ± 9.2 (p = 0.058). After prosthetic arm replacement mean DASH scores improved from 52.5 ± 9.4 to 31.2 ± 9.8 (p = 0.003). Deafferentation pain decreased from mean VAS 8.5 ± 1.0 to 6.7 ± 2.1 (p = 0.055), while the physical and mental component summary scale as part of the SF-36 health survey improved from 32.9 ± 6.4 to 40.4 ± 9.4 (p = 0.058) and 43.6 ± 8.9 to 57.3 ± 5.5 (p = 0.021), respectively. Bionic reconstruction can restore simple but robust arm and hand function in longstanding brachial plexus patients with lack of treatment alternatives.
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Affiliation(s)
- Laura A Hruby
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Clemens Gstoettner
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Agnes Sturma
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Department of Bioengineering, Imperial College London, London SW7 2AZ, UK
| | - Stefan Salminger
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Johannes A Mayer
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Eberhard Karls University Tuebingen, Schnarrenbergstraße 95, 72076 Tübingen, Germany
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
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Sturma A, Hruby LA, Prahm C, Mayer JA, Aszmann OC. Rehabilitation of Upper Extremity Nerve Injuries Using Surface EMG Biofeedback: Protocols for Clinical Application. Front Neurosci 2018; 12:906. [PMID: 30564090 PMCID: PMC6288367 DOI: 10.3389/fnins.2018.00906] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/19/2018] [Indexed: 11/13/2022] Open
Abstract
Motor recovery following nerve transfer surgery depends on the successful re-innervation of the new target muscle by regenerating axons. Cortical plasticity and motor relearning also play a major role during functional recovery. Successful neuromuscular rehabilitation requires detailed afferent feedback. Surface electromyographic (sEMG) biofeedback has been widely used in the rehabilitation of stroke, however, has not been described for the rehabilitation of peripheral nerve injuries. The aim of this paper was to present structured rehabilitation protocols in two different patient groups with upper extremity nerve injuries using sEMG biofeedback. The principles of sEMG biofeedback were explained and its application in a rehabilitation setting was described. Patient group 1 included nerve injury patients who received nerve transfers to restore biological upper limb function (n = 5) while group 2 comprised patients where biological reconstruction was deemed impossible and hand function was restored by prosthetic hand replacement, a concept today known as bionic reconstruction (n = 6). The rehabilitation protocol for group 1 included guided sEMG training to facilitate initial movements, to increase awareness of the new target muscle, and later, to facilitate separation of muscular activities. In patient group 2 sEMG biofeedback helped identify EMG activity in biologically "functionless" limbs and improved separation of EMG signals upon training. Later, these sEMG signals translated into prosthetic function. Feasibility of the rehabilitation protocols for the two different patient populations was illustrated. Functional outcome measures were assessed with standardized upper extremity outcome measures [British Medical Research Council (BMRC) scale for group 1 and Action Research Arm Test (ARAT) for group 2] showing significant improvements in motor function after sEMG training. Before actual movements were possible, sEMG biofeedback could be used. Patients reported that this visualization of muscle activity helped them to stay motivated during rehabilitation and facilitated their understanding of the re-innervation process. sEMG biofeedback may help in the cognitively demanding process of establishing new motor patterns. After standard nerve transfers individually tailored sEMG biofeedback can facilitate early sensorimotor re-education by providing visual cues at a stage when muscle activation cannot be detected otherwise.
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Affiliation(s)
- Agnes Sturma
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Health Assisting Engineering, University of Applied Sciences FH Campus Wien, Vienna, Austria.,Neuromechanics and Rehabilitation Technology Group, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Laura A Hruby
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Cosima Prahm
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Johannes A Mayer
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Oskar C Aszmann
- Christian Doppler Laboratory for Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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Bertelli JA, Ghizoni MF. Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord. J Neurosurg 2018; 2016:179-185. [PMID: 28306410 DOI: 10.3171/2014.12.jns141944.test] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.
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Affiliation(s)
- Jayme Augusto Bertelli
- Department of Neurosurgery, Southern University of Santa Catarina [Unisul], Avenida José Acácio Moreira, Tubarão, Brazil
| | - Marcos Flávio Ghizoni
- Department of Neurosurgery, Southern University of Santa Catarina [Unisul], Avenida José Acácio Moreira, Tubarão, Brazil
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Surgical strategy in extensive proximal brachial plexus palsies. Musculoskelet Surg 2018; 103:139-148. [PMID: 29961233 DOI: 10.1007/s12306-018-0552-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/24/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI). METHODS Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension. RESULTS Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%). CONCLUSIONS A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.
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Hruby LA, Pittermann A, Sturma A, Aszmann OC. The Vienna psychosocial assessment procedure for bionic reconstruction in patients with global brachial plexus injuries. PLoS One 2018; 13:e0189592. [PMID: 29298304 PMCID: PMC5751989 DOI: 10.1371/journal.pone.0189592] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/13/2017] [Indexed: 01/01/2023] Open
Abstract
Background Global brachial plexopathies cause major sensory and motor deficits in the affected arm and hand. Many patients report of psychosocial consequences including chronic pain, decreased self-sufficiency, and poor body image. Bionic reconstruction, which includes the amputation and prosthetic replacement of the functionless limb, has been shown to restore hand function in patients where classic reconstructions have failed. Patient selection and psychological evaluation before such a life-changing procedure are crucial for optimal functional outcomes. In this paper we describe a psychosocial assessment procedure for bionic reconstruction in patients with complete brachial plexopathies and present psychosocial outcome variables associated with bionic reconstruction. Methods Between 2013 and 2017 psychosocial assessments were performed in eight patients with global brachial plexopathies. We conducted semi-structured interviews exploring the psychosocial adjustment related to the accident, the overall psychosocial status, as well as motivational aspects related to an anticipated amputation and expectations of functional prosthetic outcome. During the interview patients were asked to respond freely. Their answers were transcribed verbatim by the interviewer and analyzed afterwards on the basis of a pre-defined item scoring system. The interview was augmented by quantitative evaluation of self-reported mental health and social functioning (SF-36 Health Survey), body image (FKB-20) and deafferentation pain (VAS). Additionally, psychosocial outcome variables were presented for seven patients before and after bionic reconstruction. Results Qualitative data revealed several psychological stressors with long-term negative effects on patients with complete brachial plexopathies. 88% of patients felt functionally limited to a great extent due to their disability, and all of them reported constant, debilitating pain in the deafferented hand. After bionic reconstruction the physical component summary scale increased from 30.80 ± 5.31 to 37.37 ± 8.41 (p-value = 0.028), the mental component summary scale improved from 43.19 ± 8.32 to 54.76 ± 6.78 (p-value = 0.018). VAS scores indicative of deafferentation pain improved from 7.8 to 5.6 after prosthetic hand replacement (p-value = 0.018). Negative body evaluation improved from 60.71 ± 12.12 to 53.29 ± 11.03 (p-value = 0.075). Vital body dynamics increased from 38.57 ± 13.44 to 44.43 ± 16.15 (p-value = 0.109). Conclusions Bionic reconstruction provides hope for patients with complete brachial plexopathies who have lived without hand function for years or even decades. Critical patient selection is crucial and the psychosocial assessment procedure including a semi-structured interview helps identify unresolved psychological issues, which could preclude or delay bionic reconstruction. Bionic reconstruction improves overall quality of life, restores an intact self-image and reduces deafferentation pain.
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Affiliation(s)
- Laura Antonia Hruby
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Anna Pittermann
- General Hospital of Vienna, Department of Clinical Psychology, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Agnes Sturma
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Health Assisting Engineering, University of Applied Sciences FH Campus, Vienna, Austria
| | - Oskar Christian Aszmann
- Christian Doppler Laboratory for Restoration of Extremity Function, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- * E-mail:
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Transposition of branches of radial nerve innervating supinator to posterior interosseous nerve for functional reconstruction of finger and thumb extension in 4 patients with middle and lower trunk root avulsion injuries of brachial plexus. Curr Med Sci 2017; 37:933-937. [PMID: 29270756 DOI: 10.1007/s11596-017-1830-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/06/2017] [Indexed: 10/18/2022]
Abstract
This study aimed to investigate the reconstruction of the thumb and finger extension function in patients with middle and lower trunk root avulsion injuries of the brachial plexus. From April 2010 to January 2015, we enrolled in this study 4 patients diagnosed with middle and lower trunk root avulsion injuries of the brachial plexus via imaging tests, electrophysiological examinations, and clinical confirmation. Muscular branches of the radial nerve, which innervate the supinator in the forearm, were transposed to the posterior interosseous nerve to reconstruct the thumb and finger extension function. Electrophysiological findings and muscle strength of the extensor pollicis longus and extensor digitorum communis, as well as the distance between the thumb tip and index finger tip, were monitored. All patients were followed up for 24 to 30 months, with an average of 27.5 months. Motor unit potentials (MUP) of the extensor digitorum communis appeared at an average of 3.8 months, while MUP of the extensor pollicis longus appeared at an average of 7 months. Compound muscle action potential (CMAP) appeared at an average of 9 months in the extensor digitorum communis, and 12 months in the extensor pollicis longus. Furthermore, the muscle strength of the extensor pollicis longus and extensor digitorum communis both reached grade III at 21 months. Lastly, the average distance between the thumb tip and index finger tip was 8.8 cm at 21 months. In conclusion, for patients with middle and lower trunk injuries of the brachial plexus, transposition of the muscular branches of the radial nerve innervating the supinator to the posterior interosseous nerve for the reconstruction of thumb and finger extension function is practicable and feasible.
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Sharp O, Wong KY, Stephens P. Backpack palsy with Horner's syndrome. BMJ Case Rep 2017; 2017:bcr-2017-219402. [PMID: 28536218 DOI: 10.1136/bcr-2017-219402] [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: 11/04/2022] Open
Abstract
Traumatic injuries to the brachial plexus are typically high impact and can be debilitating, life-changing injuries. Backpack palsy is a rare but well-established cause of brachial plexus injury, arising as a result of heavy backpack use. We present an unusual case of backpack palsy with Horner's syndrome.
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Affiliation(s)
- Olivia Sharp
- Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Kai Yuen Wong
- Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Paul Stephens
- Department of Plastic Surgery, Salisbury NHS Foundation Trust, Salisbury, UK
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Reichert P, Kiełbowicz Z, Dzięgiel P, Puła B, Wrzosek M, Bocheńska A, Gosk J. Effect of Collateral Sprouting on Donor Nerve Function After Nerve Coaptation: A Study of the Brachial Plexus. Med Sci Monit 2016; 22:387-96. [PMID: 26848925 PMCID: PMC4762401 DOI: 10.12659/msm.895397] [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] [Indexed: 11/23/2022] Open
Abstract
Background The aim of the present study was to evaluate the donor nerve from the C7 spinal nerve of the rabbit brachial plexus after a coaptation procedure. Assessment was performed of avulsion of the C5 and C6 spinal nerves treated by coaptation of these nerves to the C7 spinal nerve. Material/Methods After nerve injury, fourteen rabbits were treated by end-to-side coaptation (ETS), and fourteen animals were treated by side-to-side coaptation (STS) on the right brachial plexus. Electrophysiological and histomorphometric analyses and the skin pinch test were used to evaluate the outcomes. Results There was no statistically significant difference in the G-ratio proximal and distal to the coaptation in the ETS group, but the differences in the axon, myelin sheath and fiber diameters were statistically significant. The comparison of the ETS and STS groups distal to the coaptation with the controls demonstrated statistically significant differences in the fiber, axon, and myelin sheath diameters. With respect to the G-ratio, the ETS group exhibited no significant differences relative to the control, whereas the G-ratio in the STS group and the controls differed significantly. In the electrophysiological study, the ETS and STS groups exhibited major changes in the biceps and subscapularis muscles. Conclusions The coaptation procedure affects the histological structure of the nerve donor, but it does not translate into changes in nerve conduction or the sensory function of the limb. The donor nerve lesion in the ETS group is transient and has minimal clinical relevance.
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Affiliation(s)
- Pawel Reichert
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wrocław Medical University, Wrocław, Poland
| | - Zdzisław Kiełbowicz
- Department of Surgery, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Piotr Dzięgiel
- Department of Histology and Embryology, Wrocław Medical University, Wrocław, Poland
| | - Bartosz Puła
- Department of Histology and Embryology, Wrocław Medical University, Wrocław, Poland
| | - Marcin Wrzosek
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Aneta Bocheńska
- Centre of Veterinary Medicine JU-UAK, The University of Agriculture, Cracow, Poland
| | - Jerzy Gosk
- Department of Traumatology, Clinic of Traumatology and Hand Surgery, Wroclaw Medical University, Wrocław, Poland
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Bertelli JA, Ghizoni MF. Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord. J Neurosurg 2016; 124:179-85. [DOI: 10.3171/2014.12.jns141944] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord.
METHODS
The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients’ average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength).
RESULTS
After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6.
CONCLUSIONS
The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.
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Socolovsky M, di Masi G, Bonilla G, Paez MD, Robla J, Cabrera CC. The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis. Acta Neurochir (Wien) 2015; 157:1077-86; discussion 1086. [PMID: 25833303 DOI: 10.1007/s00701-015-2387-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Controversy exists surrounding the use of the phrenic nerve for transfer in severe brachial plexus injuries. The objectives of this study are: (1) to present the experience of the authors using the phrenic nerve in a single institution; and (2) to thoroughly review the existing literature to date. METHODS Adult patients with C5-D1 and C5-C8 lesions and a phrenic nerve transfer were retrospectively included. Patients with follow-up shorter than 18 months were excluded. The MRC muscle strength grading system was used to rate the outcome. Clinical repercussions relating to sectioning of the phrenic nerve were studied. An intense rehabilitation program was started after surgery, and compliance to this program was monitored using a previously described scale. Statistical analysis was performed with the obtained data. RESULTS Fifty-one patients were included. The mean time between trauma and surgery was 5.7 months. Three-quarters of the patients had C5-D1, with the remainder C5-C8. Mean post-operative follow-up was 32.5 months A MRC of M4 was achieved in 62.7% patients, M3 21.6%, M2 in 3.9%, and M1 in 11.8%. The only significant differences between the two groups were in graft length (9.8 vs. 15.1 cm, p = 0.01); and in the rehabilitation compliance score (2.86 vs. 2.00, p = 0.01). CONCLUSIONS Results of phrenic nerve transfer are predictable and good, especially if the grafts are short and the rehabilitation is adequate. It may adversely affect respiratory function tests, but this rarely correlates clinically. Contraindications to the use of the phrenic nerve exist and should be respected.
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Vergara amador EM. Lesiones altas del plexo braquial. Reconstrucción con técnicas combinadas de neurotización e injertos nerviosos. REVISTA DE LA FACULTAD DE MEDICINA 2015. [DOI: 10.15446/revfacmed.v63n1.43406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
<p>Las lesiones altas del plexo braquial son reconstruidas con neurotización e injerto nervioso. El nervio espinal accesorio, la raíz C7, ramas del tríceps, y el nervio mediano y cubital son los más usados para transferencias.</p><p>Se muestra la experiencia con neurotización de la rama inferior del nervio espinal accesorio (NEA) al nervio supraescapular (NSE), transferencia nerviosa de fascículos del nervio cubital o del mediano, y en ocasiones injertos nervioso hacia el nervio musculocutáneo y al tronco posterior, y reconstrucción del nervio axilar en algunos casos.</p><p><strong>Materiales y métodos</strong></p><p>Se revisan 42 pacientes con lesiones altas de plexo braquial, operados mediante combinación de neurotización e injertos nerviosos. Seguimiento mínimo de 15 meses.</p><p><strong>Resultados </strong></p><p>40 pacientes fueron por accidente en moto. En 22 se transfirió únicamente el NSE con el NEA, recuperando abducción de hombro de 33º En 8 pacientes que se combinó con reparación del axilar, mejoró la abducción a 81º.</p><p>En 30 pacientes con neurotización del nervio cubital o mediano para el bíceps, se obtuvo respuesta entre 3 y 4 meses. Al final flexión del codo de 116º y M4.</p><p><strong>Discusión</strong></p><p>Los mejores resultados en hombro fueron con la combinación de NSE y del nervio axilar, logrando 81º de abducción. La rotación externa mejoro en 28.5% de los pacientes, siendo una respuesta tardía</p><p>La neurotización del bíceps con fascículos del cubital consiguió una flexión de 116º, muy comparable con otras series. Hoy esta técnica es el <em>gold estándar</em> para la reconstrucción de flexión del codo. </p>
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Tendon palpation during agonist contraction and antagonist co-contraction to assess wrist flexor and extensor muscle function. ACTA ACUST UNITED AC 2015; 34:79-85. [DOI: 10.1016/j.main.2015.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/25/2014] [Accepted: 01/13/2015] [Indexed: 11/19/2022]
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Hawasli AH, Chang J, Reynolds MR, Ray WZ. Transfer of the brachialis to the anterior interosseous nerve as a treatment strategy for cervical spinal cord injury: technical note. Global Spine J 2015; 5:110-7. [PMID: 25844283 PMCID: PMC4369208 DOI: 10.1055/s-0034-1396760] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 11/03/2014] [Indexed: 01/07/2023] Open
Abstract
Study Design Technical report. Objective To provide a technical description of the transfer of the brachialis to the anterior interosseous nerve (AIN) for the treatment of tetraplegia after a cervical spinal cord injury (SCI). Methods In this technical report, the authors present a case illustration of an ideal surgical candidate for a brachialis-to-AIN transfer: a 21-year-old patient with a complete C7 spinal cord injury and failure of any hand motor recovery. The authors provide detailed description including images and video showing how to perform the brachialis-to-AIN transfer. Results The brachialis nerve and AIN fascicles can be successfully isolated using visual inspection and motor mapping. Then, careful dissection and microsurgical coaptation can be used for a successful anterior interosseous reinnervation. Conclusion The nerve transfer techniques for reinnervation have been described predominantly for the treatment of brachial plexus injuries. The majority of the nerve transfer techniques have focused on the upper brachial plexus or distal nerves of the lower brachial plexus. More recently, nerve transfers have reemerged as a potential reinnervation strategy for select patients with cervical SCI. The brachialis-to-AIN transfer technique offers a potential means for restoration of intrinsic hand function in patients with SCI.
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Affiliation(s)
- Ammar H. Hawasli
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Jodie Chang
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Matthew R. Reynolds
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Wilson Z. Ray
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, United States,Address for correspondence Wilson Z. Ray, MD Department of Neurosurgery, Washington University School of Medicine660 South Euclid Avenue, Campus Box 8057, St. Louis, MO 63110United States
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The effect of humerus diaphyseal shortening on brachial plexus tension: a cadaver study. J Hand Surg Am 2015; 40:303-7. [PMID: 25542432 DOI: 10.1016/j.jhsa.2014.10.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 10/24/2014] [Accepted: 10/24/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the extent to which diaphyseal shortening of the humerus can allow direct suture in case of rupture or transection injuries of the brachial plexus. METHODS The use of 3 fresh cadaver specimens allowed for the study of 6 brachial plexuses. Distance measurements were made between reference points placed on the clavicle and on different parts of the plexus. Those measurements were repeated after shortening the humerus by 2, 4, and 6 cm. RESULTS None of the dissected plexuses had classic anatomy. A humeral shortening of 6 cm allowed for a statistically significant reduction of length between the supraclavicular part of the plexus and the terminal branches, which did not exceed 17 mm on average. The difference of length was much greater for the specimen in which the musculocutaneous nerve did not pierce the coracobrachialis muscle proximally. CONCLUSIONS In clinical situations, nerve defects are usually larger than the gain observed when doing a 6-cm humeral shortening. Moreover, this procedure implies a large dissection, a functional loss of certain muscles, and a risk of humeral nonunion. CLINICAL RELEVANCE In the absence of extensive nerve dissection, the observed change of length is insufficient in the most brachial plexus disruptions to allow for a direct suture instead of long nerve grafts.
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Triceps innervation pattern: implications for triceps nerve to deltoid nerve transfer. BIOMED RESEARCH INTERNATIONAL 2014; 2013:132954. [PMID: 24490145 PMCID: PMC3893735 DOI: 10.1155/2013/132954] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 11/23/2013] [Indexed: 12/04/2022]
Abstract
There are multiple nerve branches supplying the triceps. Traditionally, the nerve to the long head of triceps is utilized for nerve transfer to neurotize the deltoid muscle in patients with brachial plexus injuries. However, no anatomical studies were done to investigate which triceps nerve would be preferred for nerve transfer. This anatomical study was carried out to describe the innervation pattern of the triceps muscle to investigate the preferred triceps nerve for nerve transfer. Twenty-five cadaveric arms were dissected. The long head of the triceps received a single branch in 23 cases (92%) and double branches in 2 cases (8%) only. The medial head had a single branch in 22 cases (88%) and double branches in 3 cases (12%). The lateral head was the most bulky one and received more than one branch in all cases (100%), ranging from 2 to 5 branches. The transfer of the most proximal branch to the lateral head of the triceps seems to be the most preferred choice for deltoid muscle innervation.
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Soldado F, Bertelli J. Free gracilis transfer reinnervated by the nerve to the supinator for the reconstruction of finger and thumb extension in longstanding C7-T1 brachial plexus root avulsion. J Hand Surg Am 2013; 38:941-6. [PMID: 23566721 DOI: 10.1016/j.jhsa.2013.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 02/06/2013] [Accepted: 02/07/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the clinical results of a free gracilis muscle transfer to finger and thumb extensors reinnervated by supinator muscle motor branches in patients with longstanding C7-T1 root avulsion. METHODS Between January 2010 and January 2011, 3 young adult patients with traumatic C7-T1 brachial plexus palsies had gracilis transfer to the thumb and finger extensors at a mean of 38 months after injury. The muscle flap was connected to radial vessels and comitant veins and to nerve branches supplying the supinator muscle. RESULTS All patients had recovery of active thumb and finger extension, scoring M3 and M4 on the Medical Research Council scale, respectively, at a mean of 12 months after surgery. CONCLUSIONS Reconstruction of finger and thumb extension in lower-type brachial plexus injuries is a challenging problem that is most commonly addressed with an extensor tenodesis technique, which depends on wrist flexion. Free gracilis transfer innervated by nerve branches to the supinator provided the restoration of thumb and finger extension independent of wrist flexion. CLINICAL RELEVANCE For those patients with lower brachial root injury more than a year old, transfer of a free functional gracilis muscle is an alternative for the reconstruction of thumb and finger extension. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Francisco Soldado
- Pediatric Upper Extremity Surgery and Microsurgery Department, Universitat Autonoma de Barcelona, Barcelona, Spain.
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Rezende MRD, Silva GB, Paula EJLD, Mattar Junior R, Camargo OPD. What has changed in brachial plexus surgery? Clinics (Sao Paulo) 2013; 68:411-8. [PMID: 23644864 PMCID: PMC3611894 DOI: 10.6061/clinics/2013(03)r02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 11/04/2012] [Indexed: 12/01/2022] Open
Abstract
Brachial plexus injuries, in all their severity and complexity, have been extensively studied. Although brachial plexus injuries are associated with serious and often definitive sequelae, many concepts have changed since the 1950s, when this pathological condition began to be treated more aggressively. Looking back over the last 20 years, it can be seen that the entire approach, from diagnosis to treatment, has changed significantly. Some concepts have become better established, while others have been introduced; thus, it can be said that currently, something can always be offered in terms of functional recovery, regardless of the degree of injury. Advances in microsurgical techniques have enabled improved results after neurolysis and have made it possible to perform neurotization, which has undoubtedly become the greatest differential in treating brachial plexus injuries. Improvements in imaging devices and electrical studies have allowed quick decisions that are reflected in better surgical outcomes. In this review, we intend to show the many developments in brachial plexus surgery that have significantly changed the results and have provided hope to the victims of this serious injury.
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Affiliation(s)
- Marcelo Rosa de Rezende
- Institute of Orthopedics and Traumatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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Plate JF, Ely LK, Pulley BR, Smith BP, Li Z. Combined proximal nerve graft and distal nerve transfer for a posterior cord brachial plexus injury. J Neurosurg 2012; 118:155-9. [PMID: 23140157 DOI: 10.3171/2012.10.jns12425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The treatment of patients with prolonged denervation from a posterior cord brachial plexus injury is challenging and no management guidelines exist to follow. The authors describe the case of a 26-year-old man who presented to our clinic for treatment 11 months after suffering a high-energy injury to the posterior cord of the brachial plexus. A combined 9-cm proximal cable nerve graft procedure and a pronator branch to the posterior interosseous nerve transfer were performed. Satisfactory deltoid, triceps, wrist, and finger extensor recovery was noted 3 years after surgery. Patients with prolonged denervation from posterior cord injuries can be successfully treated with a combination of a proximal nerve graft and a distal nerve transfer.
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Affiliation(s)
- Johannes F Plate
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina 27157-1070, USA
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Ray WZ, Yarbrough CK, Yee A, Mackinnon SE. Clinical outcomes following brachialis to anterior interosseous nerve transfers. J Neurosurg 2012; 117:604-9. [DOI: 10.3171/2012.6.jns111332] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The surgical management of lower brachial plexus injuries remains a challenging problem. Although nerve transfers have improved clinical outcomes following brachial plexus injuries, the majority of work has focused on upper trunk injuries. Complete lower plexus injuries often lack suitable donors for either nerve or tendon transfers. The authors describe their experience with isolated lower trunk injuries utilizing the nerve to the brachialis to reinnervate the anterior interosseous nerve.
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Affiliation(s)
| | | | - Andrew Yee
- 2Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Susan E. Mackinnon
- 2Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
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Bertelli JA, Ghizoni MF. Transfer of a flexor digitorum superficialis motor branch for wrist extension reconstruction in C5-C8 root injuries of the brachial plexus: A case series. Microsurgery 2012; 33:39-42. [DOI: 10.1002/micr.22027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 06/18/2012] [Accepted: 06/25/2012] [Indexed: 11/06/2022]
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