1
|
Doherty C, Brown E, Berger M, Seal A, Tang D, Chandler R, Bristol S. Contemporary Approaches to Peripheral Nerve Surgery. Plast Surg (Oakv) 2024; 32:516-527. [PMID: 39104941 PMCID: PMC11298148 DOI: 10.1177/22925503221120571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 08/07/2024] Open
Abstract
"State of the Art" Learning Objectives: This manuscript serves to provide the reader with a general overview of the contemporary approaches to peripheral nerve reconstruction as the field has undergone considerable advancement over the last 3 decades. The learning objectives are as follows: To provide the reader with a brief history of peripheral nerve surgery and some of the landmark developments that allow for current peripheral nerve care practices.To outline the considerations and management options for the care of patients with brachial plexopathy, spinal cord injury, and lower extremity peripheral nerve injury.Highlight contemporary surgical techniques to address terminal neuroma and phantom limb pain.Review progressive and future procedures in peripheral nerve care, such as supercharge end-to-side nerve transfers.Discuss rehabilitation techniques for peripheral nerve care.
Collapse
Affiliation(s)
- Christopher Doherty
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- ICORD, International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
| | - Erin Brown
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- ICORD, International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
| | - Michael Berger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- ICORD, International Collaboration on Repair Discoveries, Vancouver, British Columbia, Canada
| | - Alexander Seal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Tang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rowan Chandler
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean Bristol
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
2
|
Bauman MMJ, Leonel LCPC, Graepel S, Peris Celda M, Shin AY, Spinner RJ. The 2-by-2 Inch "Key Window" in the Upper Extremity: An Anatomical Appraisal of the Accessibility and Proximity of the Major Nerves and Vessels. World Neurosurg 2024; 185:e1182-e1191. [PMID: 38508385 DOI: 10.1016/j.wneu.2024.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND The brachial plexus is a network of nerves located between the neck and axilla, which receives input from C5-T1. Distally, the nerves and blood vessels that supply the arm and forearm form a medial neurovascular bundle. The purpose of this study was to illustrate that a peripheral nerve dissection via a 2 × 2 inch window would allow for identification and isolation of the major nerves and blood vessels that supply the arm and forearm. METHODS A right side formalin-fixed latex-injected cadaveric arm was transected at the proximal part of the axillary fold and included the scapular attachments. Step-by-step anatomical dissection was carried out and documented with three-dimensional digital imaging. RESULTS A 2 × 2 inch window centered 2 inches distal to the axillary fold on the medial surface of the arm enabled access to the major neurovascular structures of the arm and forearm: the median nerve, ulnar nerve, medial antebrachial cutaneous nerve, radial nerve and triceps motor branches, musculocutaneous nerve and its biceps and brachialis branches and lateral antebrachial cutaneous nerve, basilic vein and brachial artery and vein, and profunda brachii artery. CONCLUSIONS Our study demonstrates that the majority of the neurovascular supply in the arm and forearm can be accessed through a 2 × 2 inch area in the medial arm. Although this "key window" may not be entirely utilized in the operative setting, our comprehensive didactic description of peripheral nerve dissection in the cadaver laboratory can help in safer identification of complex anatomy encountered during surgical procedures.
Collapse
Affiliation(s)
- Megan M J Bauman
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, USA
| | - Luciano C P C Leonel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, USA
| | - Stephen Graepel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Peris Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Rochester, Minnesota, USA; Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
3
|
Umansky D, Elzinga K, Midha R. Surgery for mononeuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:227-249. [PMID: 38697743 DOI: 10.1016/b978-0-323-90108-6.00012-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Advancement in microsurgical techniques and innovative approaches including greater use of nerve and tendon transfers have resulted in better peripheral nerve injury (PNI) surgical outcomes. Clinical evaluation of the patient and their injury factors along with a shift toward earlier time frame for intervention remain key. A better understanding of the pathophysiology and biology involved in PNI and specifically mononeuropathies along with advances in ultrasound and magnetic resonance imaging allow us, nowadays, to provide our patients with a logical and sophisticated approach. While functional outcomes are constantly being refined through different surgical techniques, basic scientific concepts are being advanced and translated to clinical practice on a continuous basis. Finally, a combination of nerve transfers and technological advances in nerve/brain and machine interfaces are expanding the scope of nerve surgery to help patients with amputations, spinal cord, and brain lesions.
Collapse
Affiliation(s)
- Daniel Umansky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States
| | - Kate Elzinga
- Division of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Rajiv Midha
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
4
|
Mathew A, Panwar J, Shanmugasundaram D, Thomas BP. Will preoperative combined MRI and high-resolution ultrasonography redefine brachial plexus imaging? A comparative study of preoperative MRI versus combined MRI and high-resolution ultrasonography in assessing usable C5, C6 root-stumps for intra-plexal nerve grafting. Clin Radiol 2023; 78:e1023-e1031. [PMID: 37777386 DOI: 10.1016/j.crad.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/15/2023] [Accepted: 08/29/2023] [Indexed: 10/02/2023]
Abstract
AIM To compare the intraoperative findings with the preoperative imaging in detecting usable root stumps using magnetic resonance imaging (MRI) alone versus MRI combined with high-resolution ultrasonography (HRUS) in adults undergoing post-traumatic brachial plexus (BP) surgery. Further, when root stumps were present, the reliability of their measurements using both imaging methods was compared to their intraoperative length. MATERIALS AND METHODS A consecutive group of adults who were planned for post-traumatic BP surgery between July 2015 and April 2016 were evaluated prospectively. They underwent preoperative MRI and HRUS and the agreement (kappa value) between these imaging methods and their intraoperative findings in categorising roots were then compared. When stumps were present, the reliability of the extraforaminal measurements by each method were compared to their corresponding intraoperative stump length using intraclass correlation coefficients (ICC), and Bland-Altman plots. RESULTS Of the initial 60 patients, 48 patients with 82 roots were included in the study. Greater agreement was observed between HRUS and intraoperative findings in categorising BP root stumps (kappa value 0.70, SE 0.07) versus MRI and intraoperative findings (kappa value 0.42, SE 0.07). Similarly, there was a higher correlation between HRUS and intraoperative findings (ICC: 0.94, p<0.001) than that of MRI and intraoperative findings (ICC: 0.53, p<0.001) regarding stump length measurements. CONCLUSION Combining HRUS with MRI in the preoperative imaging of the adult BP injury can better predict the presence of usable nerve root stumps for intra-plexal nerve grafting. HRUS also gave reliable preoperative stump length measurements, and it was determined that a stump should be at least 1.3 cm to be deemed usable for nerve grafting.
Collapse
Affiliation(s)
- A Mathew
- Paul Brand Center for Hand Surgery, Christian Medical College, Vellore 632004, India
| | - J Panwar
- Department of Radiology, Christian Medical College, Vellore 632004, Tamil Nadu, India.
| | - D Shanmugasundaram
- Division of Epidemiology & Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - B P Thomas
- Paul Brand Center for Hand Surgery, Christian Medical College, Vellore 632004, India
| |
Collapse
|
5
|
Bateman EA, Larocerie-Salgado J, Ross DC, Miller TA, Pripotnev S. Assessment, patient selection, and rehabilitation of nerve transfers. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1267433. [PMID: 38058570 PMCID: PMC10696649 DOI: 10.3389/fresc.2023.1267433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
Peripheral nerve injuries are common and can have a devastating effect on physical, psychological, and socioeconomic wellbeing. Peripheral nerve transfers have become the standard of care for many types of peripheral nerve injury due to their superior outcomes relative to conventional techniques. As the indications for, and use of, nerve transfers expand, the importance of pre-operative assessment and post-operative optimization increases. There are two principal advantages of nerve transfers: (1) their ability to shorten the time to reinnervation of muscles undergoing denervation because of peripheral nerve injury; and (2) their specificity in ensuring proximal motor and sensory axons are directed towards appropriate motor and sensory targets. Compared to conventional nerve grafting, nerve transfers offer opportunities to reinnervate muscles affected by cervical spinal cord injury and to augment natural reinnervation potential for very proximal injuries. This article provides a narrative review of the current scientific knowledge and clinical understanding of nerve transfers including peripheral nerve injury assessment and pre- and post-operative electrodiagnostic testing, adjuvant therapies, and post-operative rehabilitation for optimizing nerve transfer outcomes.
Collapse
Affiliation(s)
- Emma A. Bateman
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | | | - Douglas C. Ross
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Thomas A. Miller
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | - Stahs Pripotnev
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| |
Collapse
|
6
|
Jawad AM, Duraku LS, Susini F, Chaudhry T, George S, Jester A, Power DM. Resect, rewire, and restore: Nerve transfer salvage of neurological deficits associated with soft tissue tumors in a retrospective cohort series at a tertiary reconstructive center. J Plast Reconstr Aesthet Surg 2023; 85:523-533. [PMID: 37280143 DOI: 10.1016/j.bjps.2023.04.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/28/2023] [Accepted: 04/07/2023] [Indexed: 06/08/2023]
Abstract
AIMS We aimed to explore the effectiveness of nerve transfer as an intervention to restore neurological deficits caused by extremity tumors through direct nerve involvement, neural compression, or as a consequence of oncological surgery. METHODS A retrospective cohort study of consecutive cases was conducted, including all patients who underwent nerve transfers to restore functional deficits in limbs following soft tissue tumor resection. The threshold for a successful nerve transfer was a BMRC motor grade of 4/5 and sensory grade of 3-3+/4 with protective sensation. RESULTS In total, 29 nerve transfers (25 motor and 4 sensory) were completed in 11 patients, aged 12-70 years at referral, over a 6-year period to 2020. This included 22 upper limb and 3 lower limb motor nerve transfers. The timing of delayed nerve transfer reconstructions was 1-15 months following primary oncological resection, with immediate simultaneous reconstructions performed in 4 cases. The threshold for success was achieved in 82% of upper limb and 33% of lower limb motor nerve transfers, while all sensory transfers were successful in restoring protective sensation. CONCLUSION Nerve transfer surgery, a well-established technique in restoring deficits following traumatic nerve injury, is further demonstrably relevant in extremity oncological reconstruction, especially as it can be performed remotely to the tumor location or resection site and introduces a healthy nerve or fascicle to rapidly reinnervate distal muscles without sacrificing major function. This study further illustrates the importance of early recognition and referral to specialist services where multi-disciplinary surgical resection and reconstructive planning can be conducted. LEVEL OF EVIDENCE IV Clinical Case Series.
Collapse
Affiliation(s)
- Ali M Jawad
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Liron S Duraku
- Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, the Netherlands
| | - Francesca Susini
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Tahseen Chaudhry
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Samuel George
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom
| | - Andrea Jester
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, United Kingdom
| | - Dominic M Power
- Department of Hand and Peripheral Nerve Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, United Kingdom; Hands Plastics and Peripheral Nerve (HaPPeN) Research Group, United Kingdom.
| |
Collapse
|
7
|
Chi D, Ha AY, Alotaibi F, Pripotnev S, Patterson BCM, Fongsri W, Gouda M, Kahn LC, Mackinnon SE. A Surgical Framework for the Management of Incomplete Axillary Nerve Injuries. J Reconstr Microsurg 2023; 39:616-626. [PMID: 36746195 DOI: 10.1055/s-0042-1757752] [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: 02/08/2023]
Abstract
BACKGROUND Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. METHODS This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. RESULTS A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. CONCLUSION A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.
Collapse
Affiliation(s)
- David Chi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Austin Y Ha
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Fawaz Alotaibi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Stahs Pripotnev
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Brendan C M Patterson
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Warangkana Fongsri
- Hand and Microsurgery Unit, Department of Orthopedic, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Mahmoud Gouda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Zagazig University, Zagazig City, Sharkia Governorate, Egypt
| | - Lorna C Kahn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Susan E Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| |
Collapse
|
8
|
Zavala A, Chuieng-Yi Lu J, Zelenski NA, Nai-Jen Chang T, Chwei-Chin Chuang D. Staged Phrenic Nerve Elongation and Free Functional Gracilis Muscle Transplantation-A Possible Option for Late Reconstruction in Chronic Brachial Plexus Injury. J Hand Surg Am 2023; 48:1058.e1-1058.e9. [PMID: 35534324 DOI: 10.1016/j.jhsa.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/26/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE In patients with late brachial plexus birth injuries, sequelae after acute flaccid myelitis, or chronic adult brachial plexus injury, donor nerves for functioning muscle transplantation are often scarce. We present the results of a potential strategy using the phrenic nerve with staged free gracilis transplantation for upper extremity reanimation in these scenarios. METHODS A retrospective review was performed on an institutional database of brachial plexus injury or patients with palsy. All patients underwent a staged reconstruction in which the ipsilateral phrenic nerve was extended by an autogenous nerve graft (PhNG), followed by free-functioning gracilis transplantation (PhNG-gracilis). RESULTS Nine patients (6 cases of late brachial plexus birth injuries, 2 of acute flaccid myelitis, and 1 of adult chronic brachial plexus injury) were included in this study. The median follow-up period following the PhNG-gracilis procedure was 27 months (range, 12-72 months). The goals of the staged PhNG and PhNG-gracilis were primarily finger extension or finger flexion. In some patients, the technique was used to improve both elbow and finger function, tunneling the muscle through the flexor compartment of the upper arm and under the mobile wad at the elbow. All patients exhibited improvement of muscle strength, including in finger extension (4 patients) from M0 to M2; finger flexion (3 patients) from M0 to M3; elbow extension (1 patient) from M0 to M2; and elbow flexion (1 patient) from M2 to M4. CONCLUSIONS A 2-stage PhNG-gracilis may restore or enhance the residual elbow and/or finger paralysis in chronic brachial plexus injuries. A minimum follow-up period of 3 years is recommended. This technique may remain useful as one of the last reconstructive options to increase power in patients with scarce donor nerves. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
Collapse
Affiliation(s)
- Abraham Zavala
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - Nicole A Zelenski
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taipei, Taiwan.
| |
Collapse
|
9
|
Graf A, Ojemakinde A, Gupta S, Zelenski NA, Levin LS. Form and Function: Technique for Free Functional Gracilis Harvest With Greater Saphenous Vein for Large Skin Paddle. Tech Hand Up Extrem Surg 2023; 27:194-198. [PMID: 37218464 DOI: 10.1097/bth.0000000000000437] [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: 05/24/2023]
Abstract
Free functional gracilis transfer is a technique for restoration of upper extremity function following brachial plexus injury, as well as muscle loss from traumatic, oncologic, and congenital causes. However, when used for the latter applications, a functional muscle as well as large skin paddle can be required. Historically, skin paddle size was limited by venous outflow of the gracilis flap, using 1 or 2 venae comitantes, and large unreliable skin paddles resulting in partial necrosis. Therefore, to restore form and function, we herein present a technique of free functional gracilis muscle harvest with inclusion of adjacent greater saphenous vein for inclusion of a large skin paddle with 2 venous drainage systems.
Collapse
Affiliation(s)
- Alexander Graf
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Akinade Ojemakinde
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Sachin Gupta
- Department of Orthopeadic Surgery, University of Pennsylvania Health System
| | - Nicole A Zelenski
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - L Scott Levin
- Department of Orthopeadic Surgery, University of Pennsylvania Health System
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA
| |
Collapse
|
10
|
Fasce I, Fiaschi P, Bianconi A, Sacco C, Staffa G, Capone C. Long-term functional recovery in C5-C6 avulsions treated with distal nerve transfers. Neurol Res 2023; 45:867-873. [PMID: 34193028 DOI: 10.1080/01616412.2021.1942410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In patients suffering from traction lesions of the brachial plexus, complete C5 and/or C6 root avulsion patients with C7 root preservation are relatively uncommon occurrences, but represent excellent candidates for surgical treatment, with satisfactory results. Shoulder abduction and extra-rotation, elbow flexion and forearm supination are lost functions restorable with surgical treatment. METHODS This single-center, prospective observational study involved a series of 27 young adults with C5 and/or C6 root complete avulsion and C7 preservation, which underwent surgical repair with double or triple nerve transfer. RESULTS Patients recovered a useful elbow flexion. Electromyographic and clinical signs of biceps reinnervation were observed in each UN-MC nerve transfer. The abduction strength recovery was M5 in 10 patients, M4 in 14 patients and M3 in 3 patients. The external rotation strength recovery was M5 in 4 patients, M4 in 18 patients, M3 in 3 patients and M2 in 2 patients. The elbow flection strength was M5 in 5 patients, M4 in 15 patients and M3 in 7 patients. Elbow extension was preserved in all cases. CONCLUSIONS The concept of 'peripheral rewiring procedures' represents an advance in the repair of the peripheral nerve injuries. Triple nerve transfer can be nowadays considered a standard treatment for isolated C5-C6 avulsions. We report our experience with the second-biggest casuistry in the literature on patients treated with this technique. We consider our outcome concerning functional recovery to be satisfying and comparable to data reported in the literature.
Collapse
Affiliation(s)
- Irene Fasce
- Department of Neurosurgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Università di Genova, Genova, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Università di Genova, Genova, Italy
| | - Andrea Bianconi
- Department of Neurosurgery, Università Degli Studi dI Torino, Torino, Italy
| | - Carlo Sacco
- Department of Peripheral Nerve Surgery, Ospedale Civile Degli Infermi, Faenza, Italy
| | - Guido Staffa
- Department of Peripheral Nerve Surgery, Ospedale Civile Degli Infermi, Faenza, Italy
| | - Crescenzo Capone
- Department of Peripheral Nerve Surgery, Ospedale Civile Degli Infermi, Faenza, Italy
| |
Collapse
|
11
|
Chuieng-Yi Lu J, An-Jou Lin J, Lee CH, Nai-Jen Chang T, Chwei-Chin Chuang D. Phrenic Nerve as an Alternative Donor for Nerve Transfer to Restore Shoulder Abduction in Severe Multiple Root Injuries of the Adult Brachial Plexus. J Hand Surg Am 2023; 48:954.e1-954.e10. [PMID: 35610117 DOI: 10.1016/j.jhsa.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/26/2022] [Accepted: 03/09/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Nerve transfer is the gold standard to restore shoulder abduction in acute brachial plexus injuries. The aim of this study was to compare the phrenic nerve (Ph) to the spinal accessory nerve (XI) as the donor nerve for this purpose. METHODS A retrospective chart review was performed on 136 patients with acute brachial plexus injuries who received a nerve transfer of the shoulder with either the Ph (94 patients) or XI (42 patients). Each group was divided into 3 subgroups based on the recipient nerve. The maximum degree of shoulder abduction was recorded after 2 years of postoperative follow-up. A generalized estimating equation model was performed to examine the variables affecting shoulder abduction over time. RESULTS The maximum degrees of shoulder abduction achieved were 61.9° ± 38.7° in patients with Ph and 51.1° ± 37.3° in patients with XI. More than M3 shoulder abduction was achieved by 67% of patients with Ph versus 59% of patients with XI. The regression analysis showed that the age at the time of surgery correlated more with the functional outcome over time than the choice of donor nerve. CONCLUSIONS In multiple root brachial plexus injuries, the Ph exhibited similar outcomes to the XI for shoulder abduction. Our routine exploration of the supraclavicular plexus exposes the Ph conveniently for nerve transfer. The phrenic nerve should be considered as an alternative when the XI is not available or is reserved for secondary reconstruction. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
Collapse
Affiliation(s)
- Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Jennifer An-Jou Lin
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Che-Hsiung Lee
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - Tommy Nai-Jen Chang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan
| | - David Chwei-Chin Chuang
- Division of Reconstructive Microsurgery, Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Linkou, Taiwan.
| |
Collapse
|
12
|
Xiang YT, Xing XX, Hua XY, Zhang YW, Xue X, Wu JJ, Zheng MX, Wang H, Xu JG. Altered Neural Pathways and Related Brain Remodeling: A Rat Study Using Different Nerve Reconstructions. Neurosurgery 2023; 93:233-243. [PMID: 36735283 DOI: 10.1227/neu.0000000000002370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Function recovery is related to cortical plasticity. The brain remodeling patterns induced by alterations in peripheral nerve pathways with different nerve reconstructions are unknown. OBJECTIVE To explore brain remodeling patterns related to alterations in peripheral neural pathways after different nerve reconstruction surgeries. METHODS Twenty-four female Sprague-Dawley rats underwent complete left brachial plexus nerve transection, together with the following interventions: no nerve repair (n = 8), grafted nerve repair (n = 8), and phrenic nerve transfer (n = 8). Resting-state functional MR images of brain were acquired at the end of seventh month postsurgery. Amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), and functional connectivity (FC) were compared among 3 groups. Behavioral observation and electromyography assessed nerve regeneration. RESULTS Compared with brachial plexus injury group, ALFF and ReHo of left entorhinal cortex decreased in nerve repair and nerve transfer groups. The nerve transfer group showed increased ALFF and ReHo than nerve repair group in left caudate putamen, right accumbens nucleus shell (AcbSh), and right somatosensory cortex. The FC between right somatosensory cortex and bilateral piriform cortices and bilateral somatosensory cortices increased in nerve repair group than brachial plexus injury and nerve transfer groups. The nerve transfer group showed increased FC between right somatosensory cortex and areas including left corpus callosum, left retrosplenial cortex, right parietal association cortex, and right dorsolateral thalamus than nerve repair group. CONCLUSION Entorhinal cortex is a key brain area in recovery of limb function after nerve reconstruction. Nerve transfer related brain remodeling mainly involved contralateral sensorimotor areas, facilitating directional "shifting" of motor representation.
Collapse
Affiliation(s)
- Yun-Ting Xiang
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiang-Xin Xing
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xu-Yun Hua
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yu-Wen Zhang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Xin Xue
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jia-Jia Wu
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Mou-Xiong Zheng
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Traumatology and Orthopedics, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - He Wang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
- Human Phenome Institute, Fudan University, Shanghai, China
- Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence (Fudan University), Ministry of Education, China
| | - Jian-Guang Xu
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Department of Rehabilitation Medicine, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, China
| |
Collapse
|
13
|
Li H, Chen J, Wang J, Zhang T, Chen Z. Review of rehabilitation protocols for brachial plexus injury. Front Neurol 2023; 14:1084223. [PMID: 37139070 PMCID: PMC10150106 DOI: 10.3389/fneur.2023.1084223] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Brachial plexus injury (BPI) is one of the most serious peripheral nerve injuries, resulting in severe and persistent impairments of the upper limb and disability in adults and children alike. With the relatively mature early diagnosis and surgical technique of brachial plexus injury, the demand for rehabilitation treatment after brachial plexus injury is gradually increasing. Rehabilitation intervention can be beneficial to some extent during all stages of recovery, including the spontaneous recovery period, the postoperative period, and the sequelae period. However, due to the complex composition of the brachial plexus, location of injury, and the different causes, the treatment varies. A clear rehabilitation process has not been developed yet. Rehabilitation therapy that has been widely studied focusing on exercise therapy, sensory training, neuroelectromagnetic stimulation, neurotrophic factors, acupuncture and massage therapy, etc., while interventions like hydrotherapy, phototherapy, and neural stem cell therapy are less studied. In addition, rehabilitation methods in some special condition and group often neglected, such as postoperative edema, pain, and neonates. The purpose of this article is to explore the potential contributions of various methods to brachial plexus injury rehabilitation and to provide a concise overview of the interventions that have been shown to be beneficial. The key contribution of this article is to form relatively clear rehabilitation processes based on different periods and populations, which provides an important reference for the treatment of brachial plexus injuries.
Collapse
|
14
|
Hill JR, Lanier ST, Rolf L, James AS, Brogan DM, Dy CJ. Trends in Brachial Plexus Surgery: Characterizing Contemporary Practices for Exploration of Supraclavicular Plexus. Hand (N Y) 2023; 18:14S-21S. [PMID: 34018448 PMCID: PMC9896279 DOI: 10.1177/15589447211014613] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons' rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus. METHODS We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI. RESULTS Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile. CONCLUSIONS Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.
Collapse
Affiliation(s)
- J. Ryan Hill
- Washington University School of
Medicine, St. Louis, MO, USA
| | | | - Liz Rolf
- Washington University School of
Medicine, St. Louis, MO, USA
| | - Aimee S. James
- Washington University School of
Medicine, St. Louis, MO, USA
| | - David M. Brogan
- Washington University School of
Medicine, St. Louis, MO, USA
| | | |
Collapse
|
15
|
Estrella EP, Montales TD. Nerve Transfers for Elbow Reconstruction in Upper and Extended Upper-Type Brachial Plexus Injuries: A Case Series. Oper Neurosurg (Hagerstown) 2022; 23:367-373. [PMID: 36227251 DOI: 10.1227/ons.0000000000000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 05/14/2022] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Nerve transfers for elbow flexion in brachial plexus injuries have been used with increasing frequency because of the higher rate of success and acceptable morbidity. This is especially true in upper and extended upper-type brachial plexus injuries. OBJECTIVE To present the clinical outcomes of nerve transfers for elbow flexion in patients with upper and extended upper-type brachial plexus injuries. METHODS A retrospective cohort review was done on all patients with upper and extended upper-type brachial plexus injuries from 2006 to 2017, who underwent nerve transfers for the restoration of elbow flexion. Outcome variables include Filipino version of the disability of the arm, shoulder, and hand (FIL-DASH) score, elbow flexion strength and range of motion, and pain. All statistical significance was set at P < .05. RESULTS Fifty-six patients with nerve transfers to restore elbow flexion were included. There was a significant improvement in FIL-DASH scores in 28 patients after the nerve transfer procedure. Patients with C56 nerve root injuries and those with more than 2 years' follow-up have a higher percentage of regaining ≥M4 elbow flexion strength. Those with double nerve transfers had a higher percentage of ≥M4 elbow flexion strength, greater range of elbow flexion, and better FIL-DASH scores compared with single nerve transfers, but this did not reach statistical significance. CONCLUSION Nerve transfer procedures improve FIL-DASH scores in upper and upper-type brachial plexus injuries. After nerve transfer, stronger elbow flexion can be expected in patients with C56 injuries, and those with longer follow-up.
Collapse
Affiliation(s)
- Emmanuel P Estrella
- Institute of Clinical Epidemiology, ASTRO Study Group, National Institutes of Health, University of the Philippines Manila, Manila, Philippines
- Microsurgery Unit, Department of Orthopedics, University of the Philippines, Manila Philippine General Hospital, Manila, Philippines
| | - Tristram D Montales
- Microsurgery Unit, Department of Orthopedics, University of the Philippines, Manila Philippine General Hospital, Manila, Philippines
| |
Collapse
|
16
|
Haldane C, Frost G, Ogalo E, Bristol S, Doherty C, Berger M. A systematic review and meta-analysis of patient-reported outcomes following nerve transfer surgery for brachial plexus injury. PM R 2022; 14:1368-1381. [PMID: 35100499 DOI: 10.1002/pmrj.12778] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 01/07/2022] [Accepted: 01/17/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this systematic review and meta-analysis was to determine the effect of nerve transfer surgery for brachial plexus injury (BPI) on patient-reported outcomes. LITERATURE SURVEY MEDLINE, EMBASE, and CINAHL were searched and screened in duplicate for relevant studies on September 25, 2019 and repeated June 24, 2020. METHODOLOGY The patient population included male and female patients who received nerve transfer surgery for BPI. Further inclusion criteria were: (1) all levels of evidence; (2) published in English; (3) conducted in humans; and (4) report of patient-reported outcome. Two reviewers independently abstracted data regarding injury type, surgical technique, surgical timing, follow-up duration, strength, and patient-reported outcome measures. Quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies criteria. SYNTHESIS Twenty-one studies involving 464 participants were included in analyses. The mean age ± SD was 32.4 ± 1.8 (range: 5-77) and 89.2% of included participants were male. The mean time to surgery was 5.6 ± 0.6 months and the mean follow-up time was 48.1 ± 8.4 months. The most used patient-reported outcome was the Disabilities of Arm, Shoulder and Hand (DASH), where scores variably improved postoperatively, although the degree of disability remained high. Return to work was reported in five studies, with 66.0% of participants returning to work. Patient satisfaction was assessed in four studies with an overall satisfaction proportion of 64.0%. Pain was assessed in 12 studies using various measures. In studies reporting pain intensity postoperatively, 29.3% of patients were "pain-free" or had "no pain." CONCLUSIONS Patient-reported outcomes following nerve transfer for BPI are infrequently reported in the literature. Although patient-reported outcomes demonstrate variable postoperative improvement, there is evidence of ongoing limitations and postoperative DASH scores report a high degree of ongoing disability. Future studies with greater reporting as well as validation of patient-reported outcomes within BPI are warranted.
Collapse
Affiliation(s)
- Chloe Haldane
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Geoffrey Frost
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emmanuel Ogalo
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean Bristol
- Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher Doherty
- Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Berger
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
17
|
Saadeh YS, Chopra Z, Olsen E, Smith BW, Kashlan ON, Yang LJS, Park P. Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy. J Neurosurg Spine 2022; 37:563-568. [PMID: 35426819 DOI: 10.3171/2022.3.spine2222] [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: 01/07/2022] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical nerve 5 palsy can occur following surgery for cervical spine pathology. The prognosis of C5 palsy is generally favorable, and most patients recover useful function. However, some patients do not recover useful strength. Nerve transfers are a potential effective treatment of postoperative severe C5 palsy. This study aimed to further delineate the natural history of recovery from postoperative C5 palsy, determine whether lack of recovery at specific time points predicts poor recovery prognosis, and thereby determine a reasonable time point for referral to a complex peripheral nerve specialist. METHODS The authors conducted a retrospective review of 72 patients who underwent surgery for cervical spondylosis and stenosis complicated by C5 palsy. Medical Research Council (MRC) motor strength grades were recorded preoperatively; immediately postoperatively; at discharge; and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Univariate and multivariate logistic regression models were used to identify demographic and clinical risk factors associated with recovery of useful strength after severe C5 palsy. RESULTS The mean patient age was 62.5 years, and 36.1% of patients were female. Thirty patients (41.7%) experienced severe C5 palsy with less than antigravity strength (MRC grade 2 or less) at discharge. Twenty-one (70%) of these patients recovered useful strength (MRC grade 3 or greater) at 12 months postoperatively, and 9 patients (30%) did not recover useful strength at 12 months. Of those patients with persistent severe C5 palsy at 3 months postoperatively, 50% recovered useful strength at 12 months. Of those patients with persistent severe C5 palsy at 6 months postoperatively, 25% recovered useful strength at 12 months. No patient with MRC grade 0 or 1 strength at 6 months postoperatively recovered useful strength. A history of diabetes was associated with the occurrence of severe C5 palsy. On multivariate analysis, female sex was associated with recovery of useful strength. CONCLUSIONS Most patients with severe C5 palsy recover useful strength in their C5 myotome within 12 months of onset. However, at 3 months postoperatively, patients with persistent severe C5 palsy had only a 50% chance of recovering useful strength by 12 months. Lack of recovery of useful strength at 3 months postoperatively is a reasonable time point for referral to a complex peripheral nerve center to establish care and to determine candidacy for nerve transfer surgery if severe C5 palsy persists.
Collapse
Affiliation(s)
| | - Zoey Chopra
- 1Department of Neurosurgery and
- 2School of Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - Eric Olsen
- 1Department of Neurosurgery and
- 2School of Medicine, University of Michigan, Ann Arbor, Michigan; and
| | - Brandon W Smith
- 3Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | | | | |
Collapse
|
18
|
Brito S, Brown T, Thomacos N. An Exploratory Study on Participation Following Brachial Plexus Injury. Occup Ther Health Care 2022:1-13. [PMID: 36018305 DOI: 10.1080/07380577.2022.2114613] [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: 01/05/2022] [Revised: 07/21/2022] [Accepted: 08/14/2022] [Indexed: 10/15/2022]
Abstract
Consequences of brachial plexus injuries (BPI) would likely impact participation, but outcomes are not well understood. This exploratory study aimed to report the participation in productive, leisure and social roles for individuals following BPI. Fourteen male participants were diagnosed with a traumatic, BPI. Descriptive data reported included demographic, injury, surgical, and participation measures. Two-sample t-tests were conducted for comparative analysis with other studies following life altering conditions.Just over two-thirds reported feeling satisfied to very satisfied with their participation in everyday life. This long-term follow up study found on-going and profound impact on participation in a range of life situations for this diagnostic group. Participation in productive roles, home duties, and physical exercise were particularly impacted and need to be prioritized during rehabilitation.
Collapse
Affiliation(s)
- Sara Brito
- Occupational Therapy Department, Federation University, Churchill, VIC, Australia
- Department of Occupational Therapy, Monash University, Frankston, VIC, Australia
| | - Ted Brown
- Department of Occupational Therapy, Monash University, Frankston, VIC, Australia
| | - Nikos Thomacos
- Department of Occupational Therapy, Monash University, Frankston, VIC, Australia
| |
Collapse
|
19
|
Surgical Interventions for Lumbosacral Plexus Injuries: A Systematic Review. Plast Reconstr Surg Glob Open 2022; 10:e4436. [PMID: 36032367 PMCID: PMC9400934 DOI: 10.1097/gox.0000000000004436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022]
Abstract
Background: Nerve reconstruction techniques for lumbosacral plexus (LSP) injuries vary. There are no clear treatment guidelines available, and summative evaluations of the literature discussing these surgeries are lacking. For these reasons, this investigation aimed to systematically review and consolidate all available literature discussing surgical interventions for LSP injuries and cohesively present patient-reported and objective postoperative outcomes. Methods: The authors conducted a systematic review using PubMed, Embase, Web of Science, ProQuest Dissertations and Theses Global (via Proquest.com), and ClinicalTrials.gov databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After title and abstract screening, identified articles were read in full and selected for inclusion based on prespecified criteria. Results: Our literature search identified 8683 potential citations, and after duplicate removal, abstract screening, and full-text review, 62 studies remained meeting inclusion and exclusion criteria. Outcomes were extracted according to the location of injury and type of surgical repair. Injuries were classified into isolated femoral nerve injuries, isolated obturator nerve injuries, isolated sciatic nerve injuries, and multilevel LSP injuries. Surgical treatment was further classified into exploration with neurolysis, direct repair, nerve grafting, and nerve transfer surgery. Conclusions: Although results vary based on the location of the injury and the surgical technique used, nerve grafts and transfers demonstrated reasonable success in improving functional and pain outcomes. Overall, isolated femoral and obturator nerve injuries had the best outcomes reported with surgical treatment. Furthermore, incomplete sciatic nerve and multilevel LSP injuries had more reported surgical options and better outcomes than complete sciatic nerve injuries.
Collapse
|
20
|
Hussain T, Khan I, Ahmed M, Beg MSA. Neurotization of musculocutaneous nerve with intercostal nerve versus phrenic nerve – A retrospective comparative study. Surg Neurol Int 2022; 13:305. [PMID: 35928324 PMCID: PMC9345130 DOI: 10.25259/sni_596_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/07/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Brachial plexus injuries are common after both blunt and penetrating traumas resulting in upper limb weakness. The nerve transfer to the affected nerve distal to the injury site is a good option where proximal stump of the nerve is unhealthy or absent which has shown early recovery and better results. Commonly used procedures to restore elbow flexion are ipsilateral phrenic or ipsilateral intercostal nerves (ICNs) in global plexus injuries. The use of both intercostal and phrenic nerves for elbow flexion is well described and there is no definite consensus on the superiority of one on another. Methods: All patients presented in the outpatient department of LNH and MC from January 2014 to December 2017 with pan plexus or upper plexus injury with no signs of improvement for at least 3 months were included in the study. After 3 months of conservative trial; surgery offered to patients. Results: A total of 25 patients (n = 25) were operated from January 2015 to December 2017. Patients were followed to record Medical Research Council (MRC) grades at 3, 6, 9, 12, and 18 months. The patients achieved at least MRC Grade 3; 70% at 12 months follow-up to 80% at 18 months in the phrenic nerve transfer group. While in the ICN transfer group, it is 86% and 100% at 12 and 18 months postoperative, respectively. Conclusion: Our study has shown better results with ICN transfers to musculocutaneous nerve, recorded on MRC grading system.
Collapse
|
21
|
Quintero ID, Buitrago ER, Ballesteros LE. The innervation of the biceps brachii and brachialis muscles in specimens with a high incidence of an accessory biceps head. J Hand Surg Eur Vol 2022; 47:761-765. [PMID: 35225060 DOI: 10.1177/17531934221080952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We describe the patterns of motor branches to the elbow flexors in 106 fresh-frozen cadaveric upper extremities from 53 donors of the Latin American mestizo race. We identified a 20% incidence of an accessory biceps head. The innervation patterns to this accessory head were specifically described and added to the Yang classification as Type IV for the biceps and Type III for the brachialis. The patterns arising from the musculocutaneous nerve to the biceps brachii were of Type I in 69%, Type II in 9%, Type III in 7% and Type IV in 11%, and to the brachialis of Type I in 77%, Type II in 11% and Type III in 9%. In 4%, the branches did not originate from the musculocutaneous nerve. We hypothesize that the branch to the accessory biceps head might be considered as a donor for nerve transfer in selected brachial plexus injuries.
Collapse
Affiliation(s)
- Iván Darío Quintero
- Laboratory of Human Anatomy, Industrial University of Santander, Santander, Colombia.,Division of Orthopaedic Surgery, Industrial University of Santander, Santander, Colombia
| | - Edna Rocío Buitrago
- Laboratory of Human Anatomy, Industrial University of Santander, Santander, Colombia.,Division of Orthopaedic Surgery, Industrial University of Santander, Santander, Colombia
| | | |
Collapse
|
22
|
Kuncoro J, Deapsari F, Suroto H. Clinical and functional outcome after different surgical approaches for brachial plexus injuries: Cohort study. Ann Med Surg (Lond) 2022; 78:103714. [PMID: 35620046 PMCID: PMC9127148 DOI: 10.1016/j.amsu.2022.103714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/26/2022] [Accepted: 05/01/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Brachial plexus injury (BPI) can result in complete loss of neurological function and reduces the quality of life. Nerve transfer, nerve grafting, external neurolysis, and free functional muscle transfer are several management options that determine the eventual outcomes. Despite various methods of treatment, hardly any literature compares directly the result of these treatment options. This study aimed to analyze differences in clinical and functional outcomes after a reconstructive surgery. Methods A cohort retrospective study was conducted on traumatic brachial plexus injured patients aged from 17 to 65 years at one hospital in Surabaya, Indonesia, from January 2009 to December 2019. All patients were divided into 4 groups depending on the types of surgery. The clinical outcomes were measured using elbow and shoulder muscle strength, elbow and shoulder range of motion (ROM), and pain level (measured using Visual Analog Scale/VAS); the functional outcomes were measured using the overall quality of life using the DASH (disabilities of the arms, shoulder, and hand) score. Results This study included 316 patients comprising of 256 males with an average age of 27.53 ± 11.37, an average time from injury to surgery of 17.74 ± 35.82 months, and average follow-up duration of 59.89 ± 37.68 months. Most cases were caused by road traffic accidents (77.22%) and most were total arm type of BPI injury (70.7%). There was no significant difference in the mean values of study parameters except in VAS (p = 0.042) as nerve grafting resulted in less pain than external neurolysis (2.27 ± 1.03 vs. 3.68 ± 1.93, respectively; p = 0.017). Besides, nerve transfer procedure also resulted in less pain compared to external neurolysis (2.99 ± 1.84 vs. 3.68 ± 1.93, respectively; p = 0.036). Conclusion We found no significant difference between types of surgery and the postsurgical outcome. A wider multicenter study was required to define the clinical and functional outcomes clearly.
Collapse
Affiliation(s)
- Jimmy Kuncoro
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia
| | - Fani Deapsari
- Cell and Tissue Bank-Regenerative Medicine, Dr Soetomo General Academic Hospital/ Faculty of Medicine, Universitas Airlangga, Surabaya, 60132, Indonesia
| | - Heri Suroto
- Department of Orthopaedic & Traumatology, Faculty of Medicine, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, 60132, Indonesia
- Cell and Tissue Bank-Regenerative Medicine, Dr Soetomo General Academic Hospital/ Faculty of Medicine, Universitas Airlangga, Surabaya, 60132, Indonesia
- Master of Hospital Management, Universitas Muhammadiyah Yogyakarta, 55183, Indonesia
| |
Collapse
|
23
|
Brogan DM, Osei DA, Colorado BS, Sneag DB, Van Voorhis A, Dy CJ. Team Approach: Management of Brachial Plexus Injuries. JBJS Rev 2022; 10:01874474-202204000-00005. [PMID: 35427254 DOI: 10.2106/jbjs.rvw.21.00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Traumatic brachial plexus injuries are relatively rare but potentially devastating injuries with substantial functional, psychological, and economic consequences. » Prompt referral (ideally within 6 weeks of injury) to a center with a team of experts experienced in the diagnosis and management of these injuries is helpful to achieving optimal outcomes. » Preoperative and intraoperative decision-making to diagnose and plan reconstructive procedures is complex and must take into account a number of factors, including the time from injury, concomitant injuries, preservation of cervical nerve roots, and the availability of intraplexal and extraplexal donor nerves for nerve transfer. » A team approach is essential to ensure accurate localization of the pathology before surgery and to maximize rehabilitation after surgery, necessitating close contact between the surgical team, physiatrists, radiologists, and therapists.
Collapse
Affiliation(s)
- David M Brogan
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Berdale S Colorado
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | | | - Anna Van Voorhis
- Program in Occupational Therapy, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher J Dy
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
24
|
Kim RB, Bounajem M, Hamrick F, Mahan MA. Optimal Donor Nerve to Restore Elbow Flexion After Traumatic Brachial Plexus Injury: A Systematic Review and Meta-Analysis. Neurosurgery 2022; 90:39-50. [PMID: 34982869 DOI: 10.1227/neu.0000000000001737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traumatic brachial plexus injuries (BPIs) often lead to devastating upper extremity deficits. Treatment frequently prioritizes restoring elbow flexion through transfer of various donor nerves; however, no consensus identifies optimal donor nerve sources. OBJECTIVE To complete a meta-analysis to assess donor nerves for restoring elbow flexion after partial and total BPI (TBPI). METHODS Original English language articles on nerve transfers to restore elbow flexion after BPI were included. Using a random-effects model, we calculated pooled, weighted effect size of the patients achieving a composite motor score of ≥M3, with subgroup analyses for patients achieving M4 strength and with TBPI. Meta-regression was performed to assess comparative efficacy of each donor nerve for these outcomes. RESULTS Comparison of the overall effect size of the 61 included articles demonstrated that intercostal nerves and phrenic nerves were statistically superior to contralateral C7 (cC7; P = .025, <.001, respectively) in achieving ≥M3 strength. After stratification by TBPI, the phrenic nerve was still superior to cC7 in achieving ≥M3 strength (P = .009). There were no statistical differences among ulnar, double fascicle, or medial pectoral nerves in achieving ≥M3 strength. Regarding M4 strength, the phrenic nerve was superior to cC7 (P = .01) in patients with TBPI and the ulnar nerve was superior to the medial pectoral nerve (P = .036) for partial BPI. CONCLUSION Neurotization of partial BPI or TBPI through the intercostal nerve or phrenic nerve may result in functional advantage over cC7. In patients with upper trunk injuries, neurotization using ulnar, median, or double fascicle nerve transfers has similarly excellent functional recovery.
Collapse
Affiliation(s)
- Robert B Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Forrest Hamrick
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
25
|
Garg SP, Hassan AM, Patel AA, Perez MM, Stoehr JR, Ketheeswaran S, Chappell AG, Galiano RD, Ko JH. Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis. J Foot Ankle Surg 2021; 60:1280-1289. [PMID: 34366221 DOI: 10.1053/j.jfas.2021.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 02/03/2023]
Abstract
Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.
Collapse
Affiliation(s)
- Stuti P Garg
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Abbas M Hassan
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anooj A Patel
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Megan M Perez
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jenna R Stoehr
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Ava G Chappell
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert D Galiano
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jason H Ko
- Division of Plastic & Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
| |
Collapse
|
26
|
Treatment Trends of Adult Brachial Plexus Injury: A Bibliometric Analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3803. [PMID: 34548999 PMCID: PMC8443812 DOI: 10.1097/gox.0000000000003803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/12/2021] [Indexed: 11/26/2022]
Abstract
Brachial plexus injury is often debilitating because it can severely impair upper extremity function and, thus, quality of life. The surgical treatment of injuries to the brachial plexus is very demanding because it requires a profound understanding of the anatomy and expertise in microsurgery. The aim of this study was to get an overview of the landscape in adult brachial plexus injury surgery, and to understand how this has changed over the years. Methods The most frequently cited articles in English relevant to adult brachial plexus injury were identified through the Web of Science online database. Results The average number of citations per article was 32.8 (median 24, range 4-158). Authors from 26 countries contributed to our list, and the US was the biggest contributor. Almost half of all nerve transfer cases were described by Asian authors. Amongst nerve transfer, the spinal accessory nerve was the preferred donor overall, except in Asia, where intercostal nerves were preferred. Distal nerve transfers were described more often than plexo-plexal and extra-plexal-to-plexal transfers. The most common grafts were sural nerve grafts and vascularized ulnar nerve grafts, which became popular in the last decade. Conclusions Our study sheds light on the regional variations in treatment trends of adult brachial plexus injury, and on the evolution of the field over the last 30 years. The articles included in our analysis are an excellent foundation for those interested in the surgical management of brachial plexus injuries.
Collapse
|
27
|
Son WC, Kim JK, Kwon S, Kim DY. Roles of preoperative and early postoperative electrodiagnosis in brachial plexus injury patients undergoing nerve transfer operations: retrospective feasibility study. J Int Med Res 2021; 49:3000605211006610. [PMID: 33866837 PMCID: PMC8054219 DOI: 10.1177/03000605211006610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this retrospective observational study was to assess the
feasibility of electrodiagnostic parameters, perioperatively, and to
discover optimal values as prognostic factors for patients with brachial
plexus injury undergoing nerve transfer operations. Methods We retrospectively reviewed the records of 11 patients who underwent nerve
transfer surgery. The patients underwent perioperative electrodiagnosis
(EDX) before and approximately 6 months after surgery. We evaluated the
compound muscle action potential (CMAP) ratio, motor unit recruitment, and
their interval changes. To evaluate motor strength, we used the Medical
Research Council (MRC) grade, 6 and 12 months after surgery. We evaluated
the relationships between improved CMAP ratio, and motor unit recruitment
and MRC grade changes 6 and 12 months postoperatively. Results All parameters increased significantly after surgery. The CMAP ratio
improvement 6 months after surgery correlated with the MRC grade change from
baseline to 12 months, with a correlation coefficient of 0.813. Conclusion EDX parameters improved significantly postoperatively, and the CMAP ratio
improvement 6 months after surgery correlated with the clinical outcomes at
1 year. The results of perioperative EDX might help establish long-term
treatment plans for patients who undergo nerve transfer surgery.
Collapse
Affiliation(s)
- Woo Chul Son
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Kwang Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sara Kwon
- Department of Rehabilitation Medicine, Kaiser Hospital, Gu-ri, Korea
| | - Dae Yul Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
28
|
El-Gammal TA, El-Sayed A, Kotb MM, Abdel-Hamid UF, El-Gammal YT. Long-Term Outcome of Phrenic Nerve Transfer in Brachial Plexus Avulsion Injuries. Ann Plast Surg 2021; 86:188-192. [PMID: 33346562 DOI: 10.1097/sap.0000000000002611] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years. PATIENTS AND METHODS Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years. RESULTS Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms. CONCLUSIONS The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.
Collapse
Affiliation(s)
- Tarek Abdalla El-Gammal
- From the Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | | | | | | | | |
Collapse
|
29
|
Bowles DR, Canseco JA, Alexander TD, Schroeder GD, Hecht AC, Vaccaro AR. The Prevalence and Management of Stingers in College and Professional Collision Athletes. Curr Rev Musculoskelet Med 2020; 13:651-662. [PMID: 32691363 PMCID: PMC7661678 DOI: 10.1007/s12178-020-09665-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW Particularly common in collision sports such as American football or rugby, stingers are a traumatic transient neuropraxia of a cervical nerve root(s) or brachial plexus that may last anywhere from minutes to hours. This review summarizes the knowledge on the diagnosis and management of stingers in college and professional collision athletes by providing an overview of their epidemiology and pathophysiology, followed by a discussion on current treatment guidelines and return-to-play recommendations. RECENT FINDINGS Despite modifications to tackling technique, increasing awareness, and various equipment options, American football continues to have a high rate of cervical spine injuries, the majority of which occur in preseason and regular season competition settings. The incidence of stingers has slowly increased among collision athletes, and nearly half of all players report sustaining at least one stinger in their career. Recent studies have shown certain anatomical changes in the cervical spine are related to acute and reoccurring stingers. Most players who experience stingers do not miss practices or games. Despite their prevalence, literature highlighting the impact of stingers on college and professional collision athletes is limited. Advances in imaging modalities and novel radiographic parameters have provided tools for screening athletes and can guide return-to-play decisions. Future research regarding appropriate screening practices for athletes with reoccurring stingers, use of protective equipment, and rehabilitation strategies are needed to identify predisposing factors, mitigate the risk of injury, and restore full functional strength and ability.
Collapse
Affiliation(s)
- Daniel R Bowles
- Rothman Orthopaedic Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - Jose A Canseco
- Rothman Orthopaedic Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Tyler D Alexander
- Rothman Orthopaedic Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - Gregory D Schroeder
- Rothman Orthopaedic Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| | - Andrew C Hecht
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA, 19107, USA
| |
Collapse
|
30
|
Approach to the Pan-brachial Plexus Injury: Variation in Surgical Strategies among Surgeons. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3267. [PMID: 33299725 PMCID: PMC7722554 DOI: 10.1097/gox.0000000000003267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 11/26/2022]
Abstract
Treatment of pan-brachial plexus injuries has evolved significantly over the past 2 decades, with refinement and introduction of new surgical techniques, particularly free functional muscle transfer. The extent to which contemporary brachial plexus surgeons utilize various techniques as part of their treatment algorithm for pan-plexus injuries and the rationale underlying these choices remain largely unknown. Methods A case scenario was posed to 12 brachial plexus surgeons during semi-structured qualitative interviews. The case involved a young patient presenting 6 weeks after a pan-plexus injury from a motorcycle accident. Surgeons were asked to formulate a treatment plan. Inductive thematic analysis was used to identify commonalities and variation in approach to treatment. Results For shoulder function, the majority of surgeons would graft from a viable C5 nerve root, if possible, though the chosen target varied. Two-thirds of the surgeons would address elbow flexion with nerve transfers, though half would combine this with a free functional muscle transfer to increase elbow flexion strength. Free functional muscle transfer was the technique of choice to restore finger flexion. Finger extension, intrinsic function, and sensation were not prioritized. Conclusions Our study sheds light on current trends in the approach to pan-plexus injuries in the U.S. and identifies areas of variability that would benefit from future study. The optimal shoulder target and the role for grafting to the MCN for elbow flexion merit further investigation. The role of FFMT plays an increasingly prominent role in treatment algorithms.
Collapse
|
31
|
Upregulation of JHDM1D-AS1 alleviates neuroinflammation and neuronal injury via targeting miR-101-3p-DUSP1 in spinal cord after brachial plexus injury. Int Immunopharmacol 2020; 89:106962. [PMID: 33039970 DOI: 10.1016/j.intimp.2020.106962] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/16/2020] [Accepted: 08/28/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Neuroinflammation in the spinal cord following acute brachial plexus injury (BPI) remains a vital cause that leads to motor dysfunction and neuropathic pain. In this study, we aim to explore the role of long non-coding RNA JHDM1D antisense 1 (JHDM1D-AS1) in mediating BPI-induced neuroinflammation and neuronal injury. METHODS A total brachial plexus root avulsion (tBPRA) model in adult rats and IL-1β-treated motor neuron-like NSC-34 cells and LPS-treated microglia cell line BV2 were conducted for in vivo and in vitro experiments, respectively. The expressions of JHDM1D-AS1, miR-101-3p and DUSP1, p38, NF-κB, TNF-α, IL-1β, and IL-6 were detected by RT-PCR and western blot seven days after tBPI. Immunohistochemistry (IHC) was used to detect neuronal apoptosis. CCK8 assay, Tunel assay and LDH kit were used for the detection of neuronal injury. The targeted relationships between JHDM1D-AS1 and miR-101-3p, miR-101-3p and DUSP1 were verified by RNA immunoprecipitation (RIP) and dual-luciferase reporter gene assay. RESULTS We found significant downregulated expression of JHDM1D-AS1 and DUSP1 but upregulated expression of miR-101-3p in the spinal cord after tBPI. Overexpression of JHDM1D-AS1 had a prominent neuroprotective effect by suppressing neuronal apoptosis and microglial inflammation through reactivation of DUSP1. Further exploration revealed that JHDM1D-AS1 may act as a competitive endogenous RNA targeting miR-101-3p, which bound on the 3'UTR of DUSP1 mRNA. In addition, overexpression of miR-101-3p could reverse the neuroprotective effects of JHDM1D-AS1 upregulation by blocking DUSP1. CONCLUSIONS JHDM1D-AS1 exerted neuroprotective and anti-inflammatory effects in a rat model of tBPI by regulating miR-101-3p/DUSP1 axis.
Collapse
|
32
|
Wade RG, Tanner SF, Teh I, Ridgway JP, Shelley D, Chaka B, Rankine JJ, Andersson G, Wiberg M, Bourke G. Diffusion Tensor Imaging for Diagnosing Root Avulsions in Traumatic Adult Brachial Plexus Injuries: A Proof-of-Concept Study. Front Surg 2020; 7:19. [PMID: 32373625 PMCID: PMC7177010 DOI: 10.3389/fsurg.2020.00019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/23/2020] [Indexed: 01/09/2023] Open
Abstract
Cross-sectional MRI has modest diagnostic accuracy for diagnosing traumatic brachial plexus root avulsions. Consequently, patients either undergo major exploratory surgery or months of surveillance to determine if and what nerve reconstruction is needed. This study aimed to develop a diffusion tensor imaging (DTI) protocol at 3 Tesla to visualize normal roots and identify traumatic root avulsions of the brachial plexus. Seven healthy adults and 12 adults with known (operatively explored) unilateral traumatic brachial plexus root avulsions were scanned. DTI was acquired using a single-shot echo-planar imaging sequence at 3 Tesla. The brachial plexus was visualized by deterministic tractography. Fractional anisotropy (FA) and mean diffusivity (MD) were calculated for injured and avulsed roots in the lateral recesses of the vertebral foramen. Compared to healthy nerves roots, the FA of avulsed nerve roots was lower (mean difference 0.1 [95% CI 0.07, 0.13]; p < 0.001) and the MD was greater (mean difference 0.32 × 10-3 mm2/s [95% CI 0.11, 0.53]; p < 0.001). Deterministic tractography reconstructed both normal roots and root avulsions of the brachial plexus; the negative-predictive value for at least one root avulsion was 100% (95% CI 78, 100). Therefore, DTI might help visualize both normal and injured roots of the brachial plexus aided by tractography. The precision of this technique and how it relates to neural microstructure will be further investigated in a prospective diagnostic accuracy study of patients with acute brachial plexus injuries.
Collapse
Affiliation(s)
- Ryckie G. Wade
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Steven F. Tanner
- National Institute for Health Research (NIHR), Leeds Biomedical Research Centre, Leeds, United Kingdom
- Department of Medical Physics and Engineering, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Irvin Teh
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - John P. Ridgway
- National Institute for Health Research (NIHR), Leeds Biomedical Research Centre, Leeds, United Kingdom
- Department of Medical Physics and Engineering, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - David Shelley
- The Advanced Imaging Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Brian Chaka
- National Institute for Health Research (NIHR), Leeds Biomedical Research Centre, Leeds, United Kingdom
| | - James J. Rankine
- Department of Radiology, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Gustav Andersson
- Department of Integrative Medical Biology (Anatomy), Faculty of Medicine, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Science (Hand and Plastic Surgery), Faculty of Medicine, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Mikael Wiberg
- Department of Integrative Medical Biology (Anatomy), Faculty of Medicine, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Science (Hand and Plastic Surgery), Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Grainne Bourke
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, United Kingdom
- Department of Integrative Medical Biology (Anatomy), Faculty of Medicine, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Science (Hand and Plastic Surgery), Faculty of Medicine, Umeå University, Umeå, Sweden
| |
Collapse
|
33
|
Smith BW, Chang KWC, Saake SJ, Yang LJS, Chung KC, Brown SH. Quantifying Real-World Upper-Limb Activity Via Patient-Initiated Movement After Nerve Reconstruction for Upper Brachial Plexus Injury. Neurosurgery 2020; 85:369-374. [PMID: 30060090 DOI: 10.1093/neuros/nyy335] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 06/21/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A critical concept in brachial plexus reconstruction is the accurate assessment of functional outcomes. The current standard for motor outcome assessment is clinician-elicited, outpatient clinic-based, serial evaluation of range of motion and muscle power. However, discrepancies exist between such clinical measurements and actual patient-initiated use. We employed emerging technology in the form of accelerometry-based motion detectors to quantify real-world arm use after brachial plexus surgery. OBJECTIVE To evaluate (1) the ability of accelerometry-based motion detectors to assess functional outcome and (2) the real-world arm use of patients after nerve transfer for brachial plexus injury, through a pilot study. METHODS Five male patients who underwent nerve transfer after brachial plexus injury wore bilateral motion detectors for 7 d. The patients also underwent range-of-motion evaluation and completed multiple patient-reported outcome surveys. RESULTS The average age of the recruits was 41 yr (±17 yr), and the average time from operation was 2 yr (±1 yr). The VT (time of use ratio) for the affected side compared to the unaffected side was 0.73 (±0.27), and the VM (magnitude ratio) was 0.63 (±0.59). VT strongly and positively correlated with shoulder flexion and shoulder abduction: 0.97 (P = .008) and 0.99 (P = .002), respectively. CONCLUSION Accelerometry-based activity monitors can successfully assess real-world functional outcomes after brachial plexus reconstruction. This pilot study demonstrates that patients after nerve transfer are utilizing their affected limbs significantly in daily activities and that recovery of shoulder function is critical.
Collapse
Affiliation(s)
- Brandon W Smith
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kate W-C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Serena J Saake
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Susan H Brown
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
34
|
Alzahrani S, Midha R. Commentary: Viable C5 and C6 Proximal Stumps Use in Reconstructive Surgery of the Adult Brachial Plexus Traction Injuries. Neurosurgery 2020; 86:E260-E262. [PMID: 31237337 DOI: 10.1093/neuros/nyz215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 03/08/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Saud Alzahrani
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rajiv Midha
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
35
|
Haninec P, Hradecky J, Mencl L. Lower subscapular nerve transfer for axillary nerve repair in upper brachial plexus palsy. Acta Neurochir (Wien) 2020; 162:135-139. [PMID: 31713155 DOI: 10.1007/s00701-019-04122-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 10/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The potential to utilize the lower subscapular nerve for brachial plexus surgery has been suggested in many anatomical studies. However, we know of no studies in the literature describing the use of the lower subscapular nerve for axillary nerve reconstruction to date. This study aimed to examine the effectiveness of this nerve transfer in patients with upper brachial plexus palsy. METHODS Of 1340 nerve reconstructions in 568 patients with brachial plexus injury performed by the senior author (P.H.), a subset of 18 patients underwent axillary nerve reconstruction using the lower subscapular nerve and constitutes the patient group for this study. The median age was 48 years, and the median time between trauma and surgery was 6 months. A concomitant radial nerve injury was found in 8 patients. RESULTS Thirteen patients completed a minimum follow-up period of 24 months. Successful deltoid recovery was defined as (1) muscle strength MRC grade ≥ 3, (2) electromyographic signs of reinnervation, and (3) increase in deltoid muscle mass. Axillary nerve reconstruction was successful in 9 of 13 patients, which represents a success rate of 69.2%. No significant postoperative weakness of shoulder internal rotation or adduction was observed after transecting the lower subscapular nerve. CONCLUSIONS The lower subscapular nerve can be used as a safe and effective neurotization tool for upper brachial plexus injury, having a success rate of 69.2% for axillary nerve repair. Our technique presents a suitable alternative for patients with concomitant radial nerve injury.
Collapse
Affiliation(s)
- Pavel Haninec
- Department of Neurosurgery, 3rd Faculty of Medicine, Charles University Hospital Kralovske Vinohrady, Srobarova 50, 100 34, Prague, Czech Republic
| | - Jan Hradecky
- Department of Neurosurgery, 3rd Faculty of Medicine, Charles University Hospital Kralovske Vinohrady, Srobarova 50, 100 34, Prague, Czech Republic
| | - Libor Mencl
- Department of Neurosurgery, 3rd Faculty of Medicine, Charles University Hospital Kralovske Vinohrady, Srobarova 50, 100 34, Prague, Czech Republic.
| |
Collapse
|
36
|
Khalifeh JM, Dibble CF, Dy CJ, Ray WZ. Cost-Effectiveness Analysis of Combined Dual Motor Nerve Transfers versus Alternative Surgical and Nonsurgical Management Strategies to Restore Shoulder Function Following Upper Brachial Plexus Injury. Neurosurgery 2019; 84:362-377. [PMID: 30371909 DOI: 10.1093/neuros/nyy015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 01/15/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Restoration of shoulder function is an important treatment goal in upper brachial plexus injury (UBPI). Combined dual motor nerve transfer (CDNT) of spinal accessory to suprascapular and radial to axillary nerves demonstrates good functional recovery with minimal risk of perioperative complications. OBJECTIVE To evaluate the cost-effectiveness of CDNT vs alternative operative and nonoperative treatments for UBPI. METHODS A decision model was constructed to evaluate costs ($, third-party payer) and effectiveness (quality-adjusted life years [QALYs]) of CDNT compared to glenohumeral arthrodesis (GA), conservative management, and nontreatment strategies. Estimates for branch probabilities, costs, and QALYs were derived from published studies. Incremental cost-effectiveness ratios (ICER, $/QALY) were calculated to compare the competing strategies. One-way, 2-way, and probabilistic sensitivity analyses with 100 000 iterations were performed to account for effects of uncertainty in model inputs. RESULTS Base case model demonstrated CDNT effectiveness, yielding an expected 21.04 lifetime QALYs, compared to 20.89 QALYs with GA, 19.68 QALYs with conservative management, and 19.15 QALYs with no treatment. The ICERs for CDNT, GA, and conservative management vs nontreatment were $5776.73/QALY, $10 483.52/QALY, and $882.47/QALY, respectively. Adjusting for potential income associated with increased likelihood of returning to work after clinical recovery demonstrated CDNT as the dominant strategy, with ICER = -$56 459.54/QALY relative to nontreatment. Probabilistic sensitivity analysis showed CDNT cost-effectiveness at a willingness-to-pay threshold of $50 000/QALY in 78.47% and 81.97% of trials with and without income adjustment, respectively. Conservative management dominated in <1% of iterations. CONCLUSION CDNT and GA are cost-effective interventions to restore shoulder function in patients with UBPI.
Collapse
Affiliation(s)
- Jawad M Khalifeh
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Christopher F Dibble
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Christopher J Dy
- Department of Orthopedic Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Wilson Z Ray
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri.,Department of Biomedical Engineering, Washington University School of Medicine, Saint Louis, Missouri
| |
Collapse
|
37
|
Abstract
In this review, we present the current role of nerve transfers in the management of nerve injuries. The outcome of a literature review comparing the results of nerve graft versus nerve transfer and the experience of select surgical societies' members regarding experience and adoption of nerve transfer are reported. Nerve transfer publications have increased more than nerve graft or repair articles. The surgeon survey revealed an increase in nerve transfers and that more motor nerve transfers have been adopted into practice compared to sensory nerve transfers. The meta-analyses and systematic reviews of motor nerve transfers for shoulder and elbow function presented variable outcomes related to donor nerve selection. Comprehensive patient assessment is essential to evaluate the immediate functional needs and consider future reconstruction that may be necessary. Optimal outcome following nerve injury may involve a combination of different surgical options and more than one type of reconstruction. Nerve transfer is a logical extension of the paradigm shift from nerve repair and nerve graft and offers a new rung on the reconstruction ladder.
Collapse
|
38
|
Wade RG, Takwoingi Y, Wormald JCR, Ridgway JP, Tanner S, Rankine JJ, Bourke G. MRI for Detecting Root Avulsions in Traumatic Adult Brachial Plexus Injuries: A Systematic Review and Meta-Analysis of Diagnostic Accuracy. Radiology 2019; 293:125-133. [DOI: 10.1148/radiol.2019190218] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
39
|
Zheng MX, Shen YD, Hua XY, Hou AL, Zhu Y, Xu WD. Cortical Reorganization in Dual Innervation by Single Peripheral Nerve. Neurosurgery 2019; 83:819-826. [PMID: 29029335 DOI: 10.1093/neuros/nyx474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 08/18/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Functional recovery after peripheral nerve injury and repair is related with cortical reorganization. However, the mechanism of innervating dual targets by 1 donor nerve is largely unknown. OBJECTIVE To investigate the cortical reorganization when the phrenic nerve simultaneously innervates the diaphragm and biceps. METHODS Total brachial plexus (C5-T1) injury rats were repaired by phrenic nerve-musculocutaneous nerve transfer with end-to-side (n = 15) or end-to-end (n = 15) neurorrhaphy. Brachial plexus avulsion (n = 5) and sham surgery (n = 5) rats were included for control. Behavioral observation, electromyography, and histologic studies were used for confirming peripheral nerve reinnervation. Cortical representations of the diaphragm and reinnervated biceps were studied by intracortical microstimulation techniques before and at months 0.5, 3, 5, 7, and 10 after surgery. RESULTS At month 0.5 after complete brachial plexus injury, the motor representation of the injured forelimb disappeared. The diaphragm representation was preserved in the "end-to-side" group but absent in the "end-to-end" group. Rhythmic contraction of biceps appeared in "end-to-end" and "end-to-side" groups, and the biceps representation reappeared in the original biceps and diaphragm areas at months 3 and 5. At month 10, it was completely located in the original biceps area in the "end-to-end" group. Part of the biceps representation remained in the original diaphragm area in the "end-to-side" group. Destroying the contralateral motor cortex did not eliminate respiration-related contraction of biceps. CONCLUSION The brain tends to resume biceps representation from the original diaphragm area to the original biceps area following phrenic nerve transfer. The original diaphragm area partly preserves reinnervated biceps representation after end-to-side transfer.
Collapse
Affiliation(s)
- Mou-Xiong Zheng
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yun-Dong Shen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Xu-Yun Hua
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Ao-Lin Hou
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yi Zhu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-Dong Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China.,Department of Central Laboratory, Jing'an District Center Hospital, Shanghai, China.,Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China.,Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, China.,Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China.,State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| |
Collapse
|
40
|
Nagano Y, Kawamura D, Terkawi A, Urita A, Matsui Y, Iwasaki N. Minimum Ten-Year Outcomes of Partial Ulnar Nerve Transfer for Restoration of Elbow Flexion in Patients with Upper Brachial Plexus Injury. J Hand Surg Asian Pac Vol 2019; 24:283-288. [PMID: 31438804 DOI: 10.1142/s2424835519500358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Partial ulnar nerve transfer to the biceps motor branch of the musculocutaneous nerve (Oberlin's transfer) is a successful approach to restore elbow flexion in patients with upper brachial plexus injury (BPI). However, there is no report on more than 10 years subjective and objective outcomes. The purpose of this study was to clarify the long-term outcomes of Oberlin's transfer based on the objective evaluation of elbow flexion strength and subjective functional evaluation of patients. Methods: Six patients with BPI who underwent Oberlin's transfer were reviewed retrospectively by their medical records. The mean age at surgery was 29.5 years, and the mean follow-up duration was 13 years. The objective functional outcomes were evaluated by biceps muscle strength using the Medical Research Council (MRC) grade at preoperative, postoperative, and final follow-up. The patient-derived subjective functional outcomes were evaluated using the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire at final follow-up. Results: All patients had MRC grade 0 (M0) or 1 (M1) elbow flexion strength before operation. Four patients gained M4 postoperatively and maintained or increased muscle strength at the final follow-up. One patient gained M3 postoperatively and at the final follow-up. Although one patient achieved M4 postoperatively, the strength was reduced to M2 due to additional disorder. The mean score of QuickDASH was 36.5 (range, 7-71). Patients were divided into two groups; three patients had lower scores and the other three patients had higher scores of QuickDASH. Conclusions: Oberlin's transfer is effective in the restoration of elbow flexion and can maintain the strength for more than 10 years. Patients with upper BPI with restored elbow flexion strength and no complicated nerve disorders have over ten-year subjective satisfaction.
Collapse
Affiliation(s)
- Yusuke Nagano
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daisuke Kawamura
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Alaa Terkawi
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Atsushi Urita
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuichiro Matsui
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| |
Collapse
|
41
|
Rezzadeh K, Donnelly M, Vieira D, Daar D, Shah A, Hacquebord J. The extent of brachial plexus injury: an important factor in spinal accessory nerve to suprascapular nerve transfer outcomes. Br J Neurosurg 2019; 34:591-594. [DOI: 10.1080/02688697.2019.1639620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Kevin Rezzadeh
- Department of Orthopaedic Surgery, New York University School of Medicine, New York, NY, USA
| | - Megan Donnelly
- Department of Orthopaedic Surgery, New York University School of Medicine, New York, NY, USA
| | - Dorice Vieira
- Sid and Ruth Lapidus Health Sciences Library, New York University School of Medicine, New York, NY, USA
| | - David Daar
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, NY, USA
| | - Ajul Shah
- All Florida Orthopedics, Saint Petersburg, FL, USA
| | - Jacques Hacquebord
- Department of Orthopaedic Surgery, New York University School of Medicine, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, NY, USA
| |
Collapse
|
42
|
Nerve Transfers-A Paradigm Shift in the Reconstructive Ladder. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2290. [PMID: 31624686 PMCID: PMC6635215 DOI: 10.1097/gox.0000000000002290] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/16/2019] [Indexed: 01/02/2023]
Abstract
Supplemental Digital Content is available in the text. In this review, we present the current role of nerve transfers in the management of nerve injuries. The outcome of a literature review comparing the results of nerve graft versus nerve transfer and the experience of select surgical societies’ members regarding experience and adoption of nerve transfer are reported. Nerve transfer publications have increased more than nerve graft or repair articles. The surgeon survey revealed an increase in nerve transfers and that more motor nerve transfers have been adopted into practice compared to sensory nerve transfers. The meta-analyses and systematic reviews of motor nerve transfers for shoulder and elbow function presented variable outcomes related to donor nerve selection. Comprehensive patient assessment is essential to evaluate the immediate functional needs and consider future reconstruction that may be necessary. Optimal outcome following nerve injury may involve a combination of different surgical options and more than one type of reconstruction. Nerve transfer is a logical extension of the paradigm shift from nerve repair and nerve graft and offers a new rung on the reconstruction ladder.
Collapse
|
43
|
Recovery of shoulder abduction in traumatic brachial plexus palsy: a systematic review and meta-analysis of nerve transfer versus nerve graft. Neurosurg Rev 2019; 43:951-956. [DOI: 10.1007/s10143-019-01100-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
|
44
|
Nwawka OK, Casaletto E, Wolfe SW, Feinberg JH. Ultrasound imaging of brachial plexus trauma in gunshot injury. Muscle Nerve 2019; 59:707-711. [PMID: 30847944 DOI: 10.1002/mus.26461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/26/2019] [Accepted: 03/05/2019] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Brachial plexus trauma related to gunshot (GS) injury requires early examination and characterization to ensure appropriate treatment. Magnetic resonance imaging (MRI) may be contraindicated when there are metal fragments in a patient's body. Ultrasound (US) may present an alternative to imaging GS-related brachial plexus injury. METHODS Three patients with GS-related brachial plexus injury who underwent US imaging evaluation at our institution were identified. A retrospective review of the patients' medical records was performed. RESULTS US characterization of nerve abnormalities after GS injury to the brachial plexus was in agreement with electrodiagnostic and intraoperative findings. DISCUSSION Information from the US reports was useful in preparation for brachial plexus reconstruction surgery. As such, US has unique utility when MRI cannot be performed. US imaging can provide useful characterization of the brachial plexus after GS injury when performed by an experienced operator. Muscle Nerve 59:707-711, 2019.
Collapse
Affiliation(s)
- O Kenechi Nwawka
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, New York, New York, 10021, USA
| | - Emily Casaletto
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, New York, New York, 10021, USA
| | - Scott W Wolfe
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E 70th Street, New York, New York 10021, USA
| | - Joseph H Feinberg
- Department of Physiatry, Hospital for Special Surgery, 535 E 70th Street, New York, New York 10021, USA
| |
Collapse
|
45
|
Midha R, Grochmal J. Surgery for nerve injury: current and future perspectives. J Neurosurg 2019; 130:675-685. [PMID: 30835708 DOI: 10.3171/2018.11.jns181520] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Abstract
In this review article, the authors offer their perspective on nerve surgery for nerve injury, with a focus on recent evolution of management and the current surgical management. The authors provide a brief historical perspective to lay the foundations of the modern understanding of clinical nerve injury and its evolving management, especially over the last century. The shift from evaluation of the nerve injury using macroscopic techniques of exploration and external neurolysis to microscopic interrogation, interfascicular dissection, and internal neurolysis along with the use of intraoperative electrophysiology were important advances of the past 50 years. By the late 20th century, the advent and popularization of interfascicular nerve grafting techniques heralded a major advance in nerve reconstruction and allowed good outcomes to be achieved in a large percentage of nerve injury repair cases. In the past 2 decades, there has been a paradigm shift in surgical nerve repair, wherein surgeons are not only directing the repair at the injury zone, but also are deliberately performing distal-targeted nerve transfers as a preferred alternative in an attempt to restore function. The peripheral rewiring approach allows the surgeon to convert a very proximal injury with long regeneration distances and (often) uncertain outcomes to a distal injury and repair with a greater potential of regenerative success and functional recovery. Nerve transfers, originally performed as a salvage procedure for severe brachial plexus avulsion injuries, are now routinely done for various less severe brachial plexus injuries and many other proximal nerve injuries, with reliably good to even excellent results. The outcomes from nerve transfers for select clinical nerve injury are emphasized in this review. Extension of the rewiring paradigm with nerve transfers for CNS lesions such as spinal cord injury and stroke are showing great potential and promise. Cortical reeducation is required for success, and an emerging field of rehabilitation and restorative neurosciences is evident, which couples a nerve transfer procedure to robotically controlled limbs and mind-machine interfacing. The future for peripheral nerve repair has never been more exciting.
Collapse
Affiliation(s)
- Rajiv Midha
- 1Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada; and
| | - Joey Grochmal
- 2Neurosurgery, University Medical Center, Lubbock, Texas
| |
Collapse
|
46
|
Organizing a Multidisciplinary Research Team: Strategies, Execution, and Outcomes. Plast Reconstr Surg 2019; 143:951-961. [PMID: 30817669 DOI: 10.1097/prs.0000000000005326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Maintaining a competitive edge is increasingly imperative for surgical research teams. To publish as efficiently and effectively as possible, research teams should apply business strategies and theories in everyday practice. Drawing from concrete examples in both the corporate and nonprofit worlds, and by reflecting on the practices of the Michigan Comprehensive Hand Center for Innovation Research, this article identifies important business theories that can be applied to plastic surgery research. These theories can potentially be applied in practice and include (1) development of a realistic vision and strategies, (2) effective execution of these strategies, and (3) reflective evaluation for continual improvement.
Collapse
|
47
|
Ayhan E, Soldado F, Fontecha CG, Bertelli JA, Leblebicioglu G. Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study. Microsurgery 2019; 40:79-86. [PMID: 30761593 DOI: 10.1002/micr.30440] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/06/2019] [Accepted: 01/25/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury. METHODS PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed. RESULTS In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022). CONCLUSIONS Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery. LEVEL OF EVIDENCE Level II.
Collapse
Affiliation(s)
- Egemen Ayhan
- Department of Orthopaedics and Traumatology - Hand Surgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Universitari Vall Hebron, Barcelona, Spain and UCA unit, Hospital Vithas San Jose, Vitoria, Spain
| | - César G Fontecha
- Pediatric Orthopedic Unit, Vall d'Hebron Hospital. Universitat de Barcelona, Barcelona, Spain
| | - Jayme A Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Gursel Leblebicioglu
- Department of Orthopaedics and Traumatology, Division of Hand Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
48
|
The Multidisciplinary Approach to the Diagnosis and Management of Nonobstetric Traumatic Brachial Plexus Injuries. AJR Am J Roentgenol 2018; 211:1319-1331. [DOI: 10.2214/ajr.18.19887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
49
|
Traumatic upper plexus palsy: Is the exploration of brachial plexus necessary? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:255-262. [DOI: 10.1007/s00590-018-2345-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 11/25/2018] [Indexed: 12/15/2022]
|
50
|
|