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Solaja O, Baergen AK, Head LK, Wolff GK, Boyd KU. Clinical Outcomes of Upper Extremity Nerve Transfers in Neuralgic Amyotrophy. Plast Reconstr Surg 2023; 152:1072e-1075e. [PMID: 37036330 DOI: 10.1097/prs.0000000000010519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
SUMMARY Neuralgic amyotrophy (NA) is a disease affecting peripheral nerves. Treatment has historically been conservative, as the natural course of the disease was thought to be self-limiting. Recent work has demonstrated that as many as two-thirds of people with NA have persistent pain, fatigue, or weakness. At the authors' center, supercharged end-to-side (SETS) nerve transfers are commonly performed in patients with NA to optimize motor recovery while allowing for native axonal regrowth. The authors describe the technique and clinical outcomes of patients with NA affecting the anterior interosseous nerve (AIN) who were treated with SETS nerve transfer from extensor carpi radialis brevis to AIN. Ten patients (90% male; mean age, 51.3 ± 9.7 years) underwent extensor carpi radialis brevis-to-AIN transfer at a mean period of 6.4 ± 1.4 months after onset of symptoms. Mean postoperative follow-up duration was 14.8 ± 3.2 months. Before surgery, all patients demonstrated clinically significant weakness in the flexor pollicis longus (FPL), flexor digitorum profundus muscle to the index finger (FDP2), or both. FPL strength improved from a median Medical Research Council (MRC) grade of 1.5 to 4 ( P = 0.011) and FDP2 strength improved from a median MRC grade of 1 to 5 ( P = 0.016). A postoperative MRC grade of 4 or greater was achieved in nine of 10 (90%) FPL and 10 of 10 (100%) FDP muscles. This is the first report of SETS nerve transfer for the treatment of NA. The outcomes of this work suggest that SETS nerve transfers may be an option to optimize motor outcomes in patients with NA. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Ogi Solaja
- From the Divisions of Plastic and Reconstructive Surgery
| | | | - Linden K Head
- From the Divisions of Plastic and Reconstructive Surgery
| | - Gerald K Wolff
- Physical Medicine and Rehabilitation, University of Ottawa
| | - Kirsty U Boyd
- From the Divisions of Plastic and Reconstructive Surgery
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Bateman EA, Larocerie-Salgado J, Ross DC, Miller TA, Pripotnev S. Assessment, patient selection, and rehabilitation of nerve transfers. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1267433. [PMID: 38058570 PMCID: PMC10696649 DOI: 10.3389/fresc.2023.1267433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
Peripheral nerve injuries are common and can have a devastating effect on physical, psychological, and socioeconomic wellbeing. Peripheral nerve transfers have become the standard of care for many types of peripheral nerve injury due to their superior outcomes relative to conventional techniques. As the indications for, and use of, nerve transfers expand, the importance of pre-operative assessment and post-operative optimization increases. There are two principal advantages of nerve transfers: (1) their ability to shorten the time to reinnervation of muscles undergoing denervation because of peripheral nerve injury; and (2) their specificity in ensuring proximal motor and sensory axons are directed towards appropriate motor and sensory targets. Compared to conventional nerve grafting, nerve transfers offer opportunities to reinnervate muscles affected by cervical spinal cord injury and to augment natural reinnervation potential for very proximal injuries. This article provides a narrative review of the current scientific knowledge and clinical understanding of nerve transfers including peripheral nerve injury assessment and pre- and post-operative electrodiagnostic testing, adjuvant therapies, and post-operative rehabilitation for optimizing nerve transfer outcomes.
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Affiliation(s)
- Emma A. Bateman
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | | | - Douglas C. Ross
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Thomas A. Miller
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | - Stahs Pripotnev
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
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Chu TH, Alzahrani S, McConnachie A, Lasaleta N, Kalifa A, Pathiyil R, Midha R. Perineurial Window is Critical for Experimental Reverse End-to-Side Nerve Transfer. Neurosurgery 2023; 93:952-960. [PMID: 37018413 DOI: 10.1227/neu.0000000000002481] [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: 12/07/2022] [Accepted: 02/08/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The depth of connective tissue window in the side of a recipient nerve in reverse end-to-side transfers (RETS) remains controversial. OBJECTIVE To test whether the depth of connective tissue disruption influences the efficiency of donor axonal regeneration in the context of RETS. METHODS Sprague-Dawley rats (n = 24) were assigned to 1 of the 3 groups for obturator nerve to motor femoral nerve RETS: group 1, without epineurium opening; group 2, with epineurium only opening; and group 3, with epineurium and perineurium opening. Triple retrograde labeling was used to assess the number of motor neurons that had regenerated into the recipient motor femoral branch. Thy1-GFP rats (n = 8) were also used to visualize the regeneration pathways in the nerve transfer networks at 2- and 8-week time point using light sheet fluorescence microscopy. RESULTS The number of retrogradely labeled motor neurons that had regenerated distally toward the target muscle was significantly higher in group 3 than that in groups 1 and 2. Immunohistochemistry validated the degree of connective tissue disruption among the 3 groups, and optical tissue clearing methods demonstrated donor axons traveling outside the fascicles in groups 1 and 2 but mostly within the fascicles in group 3. CONCLUSION Creating a perineurial window in the side of recipient nerves provides the best chances of robust donor axonal regeneration across the RETS repair site. This finding aids nerve surgeons by confirming that a deep window should be undertaken when doing a RETS procedure.
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Affiliation(s)
- Tak-Ho Chu
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Saud Alzahrani
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Amanda McConnachie
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Nicolas Lasaleta
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Amira Kalifa
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Rajesh Pathiyil
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Rajiv Midha
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
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Gontre G, Polmear M, Carter JT, Castagno C, Herrera FA. Primary Repair versus Reverse End-to-Side Coaptation by Anterior Interosseous Nerve Transfer in Proximal Ulnar Nerve Injuries. Plast Reconstr Surg 2023; 152:384-393. [PMID: 36912900 DOI: 10.1097/prs.0000000000010395] [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: 03/14/2023]
Abstract
BACKGROUND Proximal ulnar nerve lacerations are challenging to treat because of the complex integration of sensory and motor function in the hand. The purpose of this study was to compare primary repair and primary repair plus anterior interosseous nerve (AIN) reverse end-to-side (RETS) coaptation in the setting of proximal ulnar nerve injuries. METHODS A prospective cohort study was performed of all patients at a single, academic, level I trauma center from 2014 to 2018 presenting with isolated complete ulnar nerve lacerations. Patients underwent either primary repair (PR) only or primary repair and AIN RETS (PR + RETS). Data collected included demographic information; quick Disabilities of the Arm, Shoulder and Hand questionnaire score; Medical Research Council score; grip and pinch strength; and visual analogue scale pain scores at 6 and 12 months postoperatively. RESULTS Sixty patients were included in the study: 28 in the PR group and 32 in the RETS + PR group. There was no difference in demographic variables or location of injury between the two groups. Average quick Disabilities of the Arm, Shoulder and Hand questionnaire scores for the PR and PR + RETS groups were 65 ± 6 and 36 ± 4 at 6 months and 46 ± 4 and 24 ± 3 at 12 months postoperatively, respectively, and were significantly lower in the PR + RETS group at both points. Average grip and pinch strength were significantly greater for the PR + RETS group at 6 and 12 months. CONCLUSION This study demonstrated that primary repair of proximal ulnar nerve injuries plus AIN RETS coaptation yielded superior strength and improved upper extremity function when compared with PR alone. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
- Gil Gontre
- From the Department of Orthopaedics, Texas Tech University Health Science Center
| | - Michael Polmear
- From the Department of Orthopaedics, Texas Tech University Health Science Center
| | - Jordan T Carter
- From the Department of Orthopaedics, Texas Tech University Health Science Center
| | - Christopher Castagno
- From the Department of Orthopaedics, Texas Tech University Health Science Center
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Walsh AR, Beutel BG, Tordjman D, da Costa AC, Melamed E. Neuroma-in-continuity: a review of pathophysiology and approach to the affected patient. HAND SURGERY & REHABILITATION 2023; 42:103-108. [PMID: 36758942 DOI: 10.1016/j.hansur.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
A neuroma-in-continuity is a neuroma resulting from a nerve injury in which internal neuronal elements are partially disrupted (with a variable degree of disruption to the endoneurium and perineurium) while the epineurium typically remains intact. The portion of injured axons are misdirected and embedded in connective tissue, which may give rise to local neuroma pain and a distal nerve deficit. The lesion may result from a multitude of injury mechanisms, and clinical presentation is often variable depending on the nerve affected. Clinical, electrodiagnostic, and imaging examinations are helpful in assessing the extent and degree of the lesion. If no clear evidence of recovery is identified within 3-4 months post-injury, the patient may benefit from operative exploration. Surgical management options include neurolysis, neuroma resection, nerve grafting, and nerve transfer, or a combination of modalities. A primary consideration of surgery is the possibility of further downgrading nerve function in the pursuit of more, thereby highlighting the need to carefully weigh the advantages and disadvantages prior to surgical intervention. The objective of this review article is to describe the current understanding of the pathophysiology of neuroma-in-continuity lesions, and to review the approach to the affected patient including clinical evaluation, ancillary testing, and intraoperative assessment and treatment options.
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Affiliation(s)
- Amanda R Walsh
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, New York, 11373, USA.
| | - Bryan G Beutel
- Kansas City University, 1750 Independence Avenue, Kansas City, Missouri, 64106, USA.
| | - Daniel Tordjman
- Hand Surgery Unit, Orthopedic Division, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906 Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, P.O.B 39040, Ramat Aviv, Tel Aviv, Israel.
| | - Antonio Carlos da Costa
- Hand Surgery Division, Department of Orthopedics and Traumatology, Faculdade de Ciencias Medicas Santa Casa da Misericordia de São Paulo, R. Jaguaribe, 155 - Vila Buarque, São Paulo, Brazil.
| | - Eitan Melamed
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, New York, 11373, USA.
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Pathiyil RK, Alzahrani S, Midha R. Reverse End-to-Side Transfer to Ulnar Motor Nerve: Evidence From Preclinical and Clinical Studies. Neurosurgery 2023; 92:667-679. [PMID: 36757319 DOI: 10.1227/neu.0000000000002325] [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: 10/06/2022] [Accepted: 10/26/2022] [Indexed: 02/10/2023] Open
Abstract
The disappointing outcomes of conventional nerve repair or grafting procedures for proximal ulnar nerve injuries have led the scientific community to search for better alternatives. The pronator quadratus branch of the anterior interosseous nerve has been transferred to the distal ulnar motor branch in a reverse end-to-side fashion with encouraging results. This transfer is now becoming commonly used as an adjunct to cubital tunnel decompression in patients with compressive ulnar neuropathy, underscoring the need for this knowledge transfer to the neurosurgical community. However, the mechanism of recovery after these transfers is not understood completely. We have reviewed the existing preclinical and clinical literature relevant to this transfer to summarize the current level of understanding of the underlying mechanisms, define the indications for performing this transfer in the clinic, and identify the complications and best practices with respect to the operative technique. We have also attempted to identify the major deficiencies in our current level of understanding of the recovery process to propose directions for future research.
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Affiliation(s)
- Rajesh Krishna Pathiyil
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
Partial nerve recovery either after expectant observation following an injury in-continuity or after nerve repair is not an uncommon occurrence. Historically, treatment strategies in these situations-late repair, revision repair, or acceptance of a mediocre result-were unsatisfying. The reverse end-to-side, or supercharging, nerve transfer was conceived to offer a more palatable option. Partially validated primarily through small animal research, supercharging has been rapidly translated to clinical practice. Many have extended the indications beyond the original intent, though the final place of this technique in the peripheral nerve surgeon's armamentarium is still yet to be determined.
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Affiliation(s)
- Jonathan Isaacs
- Virginia Commonwealth University Medical Center, Richmond, USA
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Errante EL, Diaz A, Smartz T, Khan A, Silvera R, Brooks AE, Lee YS, Burks SS, Levi AD. Optimal Technique for Introducing Schwann Cells Into Peripheral Nerve Repair Sites. Front Cell Neurosci 2022; 16:929494. [PMID: 35846565 PMCID: PMC9283978 DOI: 10.3389/fncel.2022.929494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Peripheral nerve injury (PNI) is found in a relatively large portion of trauma patients. If the injury is severe, such as with the presence of a long segmental gap, PNI can present a challenge for treatment. The current clinical standard of nerve harvest for the repair of long segmental gap PNI can lead to many potential complications. While other methods have been utilized, recent evidence indicates the relevance of cell therapies, particularly through the use of Schwann cells, for the treatment of PNI. Schwann cells (SCs) are integral in the regeneration and restoration of function following PNI. SCs are able to dedifferentiate and proliferate, remove myelin and axonal debris, and are supportive in axonal regeneration. Our laboratory has demonstrated that SCs are effective in the treatment of severe PNI when axon guidance channels are utilized. However, in order for this treatment to be effective, optimal techniques for cellular placement must be used. Thus, here we provide relevant background information, preclinical, and clinical evidence for our method in the treatment of severe PNI through the use of SCs and axon guidance channels.
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Affiliation(s)
- Emily L. Errante
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Anthony Diaz
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Taylor Smartz
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Aisha Khan
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Risset Silvera
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Adriana E. Brooks
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Yee-Shuan Lee
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - S. Shelby Burks
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Allan D. Levi
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- *Correspondence: Allan D. Levi
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Xie Q, Shao X, Song X, Wang F, Zhang X, Wang L, Zhang Z, Lyu L. Ulnar nerve decompression and transposition with versus without supercharged end-to-side motor nerve transfer for advanced cubital tunnel syndrome: a randomized comparison study. J Neurosurg 2021; 136:845-855. [PMID: 34479189 DOI: 10.3171/2021.2.jns203508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this prospective randomized study was to compare ulnar nerve decompression and anterior subfascial transposition with versus without supercharged end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer for advanced cubital tunnel syndrome, to describe performing the nerve transfer through a small incision, and to investigate predictive factors for poor recovery following the procedure. METHODS Between January 2013 and October 2016, 93 patients were randomly allocated to a study group (n = 45) and a control group (n = 48). Patients in the study group were treated with supercharged motor nerve transfer via a 5-cm incision following decompression and anterior subfascial transposition. Patients in the control group were treated with decompression and anterior subfascial transposition alone. Postoperative pinch strength and compound muscle action potential amplitude (CMAPa) were assessed. Function of the limb was assessed based on the Gabel/Amadio scale. Between-group data were compared, and significance was set at p < 0.05. Potential risk factors were collected from demographic data and disease severity indicators. RESULTS At the final follow-up at 2 years, the results of the study group were superior to those of the control group with regard to postoperative pinch strength (75.13% ± 7.65% vs 62.11% ± 6.97%, p < 0.05); CMAPa of the first dorsal interossei (17.17 ± 5.84 mV vs 12.20 ± 4.09 mV, p < 0.01); CMAPa of abductor digiti minimi (11.57 ± 4.04 mV vs 8.43 ± 6.11 mV, p < 0.01); and excellent to good results (0.67 for the study group vs 0.35 for the control group, p < 0.05). Multivariate analysis showed that the advanced age (OR 2.98, 95% CI 2.25-4.10; p = 0.003) in the study group was related to unsatisfactory outcome in the patients. CONCLUSIONS In the treatment of advanced cubital tunnel syndrome, additional supercharged end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer may produce a better function of the hand. The authors also found that cases in the elderly were related to unsatisfactory postoperative results for these patients and that they could be informed of the possibility of worsening surgery results.
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Affiliation(s)
- Qing Xie
- 1Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei; and
| | - Xinzhong Shao
- 1Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei; and
| | - Xiaoliang Song
- 2Department of Orthopedics, Changzhi Second People's Hospital, Changzhi, Shanxi, China
| | - Fengyu Wang
- 1Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei; and
| | - Xu Zhang
- 1Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei; and
| | - Li Wang
- 1Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei; and
| | - Zhemin Zhang
- 1Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei; and
| | - Li Lyu
- 1Department of Hand Surgery, The Third Affiliated Hospital of Hebei Medical University, Shijiazhuang, Hebei; and
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Brito da Silva H, Midha R. Editorial. Distal end-to-side motor transfer to augment ulnar nerve entrapment surgery at elbow. J Neurosurg 2021; 136:840-842. [PMID: 34479208 DOI: 10.3171/2021.2.jns21291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Harley Brito da Silva
- 1Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Rajiv Midha
- 1Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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von Guionneau N, Sarhane KA, Brandacher G, Hettiaratchy S, Belzberg AJ, Tuffaha S. Mechanisms and outcomes of the supercharged end-to-side nerve transfer: a review of preclinical and clinical studies. J Neurosurg 2020; 134:1590-1598. [PMID: 32470926 DOI: 10.3171/2020.3.jns191429] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
Proximal peripheral nerve injuries often result in poor functional outcomes, chiefly because of the long time period between injury and the reinnervation of distal targets, which leads to muscle and Schwann cell atrophy. The supercharged end-to-side (SETS) nerve transfer is a recent technical innovation that introduces donor axons distally into the side of an injured nerve to rapidly innervate and support end organs while allowing for additional reinnervation after a proximal repair at the injury site. However, the mechanisms by which donor axons grow within the recipient nerve, contribute to muscle function, and impact the regeneration of native recipient axons are poorly understood. This uncertainty has slowed the transfer's clinical adoption. The primary objective of this article is to comprehensively review the mechanisms underpinning axonal regeneration and functional recovery after a SETS nerve transfer. A secondary objective is to report current clinical applications in the upper limb and their functional outcomes. The authors also propose directions for future research with the aim of maximizing the clinical utility of the SETS transfer for peripheral nerve surgeons and their patients.
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Affiliation(s)
- Nicholas von Guionneau
- Departments of1Plastic and Reconstructive Surgery and.,3Department of Brain Sciences, Imperial College London; and
| | | | | | - Shehan Hettiaratchy
- 4Department of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | - Allan J Belzberg
- 2Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sami Tuffaha
- Departments of1Plastic and Reconstructive Surgery and
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Qian T, Qian K, Xu T, Shi J, Ma T, Song Z, Xu C, Li L. Efficacy evaluation of personalized coaptation in neurotization for motor deficit after peripheral nerve injury: A systematic review and meta-analysis. Brain Behav 2020; 10:e01582. [PMID: 32129004 PMCID: PMC7177589 DOI: 10.1002/brb3.1582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Peripheral neurotization, recently as a promising approach, has taken effect in recovering motor function after damage to a peripheral nerve root. Neural anastomosis comprised of nerve conduit and neurorrhaphy participates in the nerve reconstruction. Current literature lacks evidence supporting an individualized coaptation for rescue of locomotor loss in rat subjects with paraplegia secondary to peripheral nerve injury (PNI). METHODS This meta-analysis intends to qualify the specificity of gap-specific coaptation in treating a paralyzed limb following PNI. We used a highly sensitive search strategy to identify all published studies in multiple databases up to 1 May 2019. All identified trials were systematically evaluated using specific inclusion and exclusion criteria. Cochrane methodology was also applied to the results of this study. RESULTS Twelve studies, including 349 rat subjects, met eligibility criteria. For a medium nerve defect (0.5-3.0 cm), nerve conduit was more likely than neurorrhaphy to precipitate axon regeneration and improve motor outcome of the hemiplegic limb (OR = 3.61, 95% CI = 1.80, 7.26, p < .0003) at 3-month follow-up, whereas neurorrhaphy might take its place in promoting limb motor function in a small nerve gap (<0.5 cm) (OR = 0.48, 95% CI = 0.22, 1.07, p < .007). For a small nerve defect, nerve conduit still demonstrated visible effectiveness in recovery of limb motion albeit poorer than neurorrhaphy (OR = 1.50, 95% CI = 0.92, 2.47, p < .05). CONCLUSION Selective neurotization facilitates motor regeneration after nerve transection, and advisable choice of neural coaptation can maximize functional outcome on an individual basis.
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Affiliation(s)
- TengDa Qian
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Jintan Hospital affiliated to Jiangsu University, Jintan, China
| | - Kai Qian
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - TuoYe Xu
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Shi
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Ma
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of Neurosurgery, Changzhou first people's Hospital, Suzhou University, Changzhou, China
| | - ZeWu Song
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - ChengMing Xu
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - LiXin Li
- Department of Neurosurgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Vachata P, Brusakova S, Lodin J, Sames M. Masseteric nerve supercharge bypass in primary reconstruction of facial nerve. Acta Neurochir (Wien) 2019; 161:1089-1094. [PMID: 30980244 DOI: 10.1007/s00701-019-03901-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/28/2019] [Indexed: 11/25/2022]
Abstract
Facial paralysis is a severe disease and presents a formidable treatment challenge. A wide variety of surgical procedures are available with limited evidence. Major risk factors of suboptimal recovery include the duration of paralysis as well as higher age. In this paper, we demonstrate reconstruction of the facial nerve via an intratemporal end-to-end anastomosis and concomitant transfer of an intact masseteric nerve to the side of facial nerve trunk. The supercharge (reverse end-to-side) transfer resulted in preservation of target muscles and faster recovery. Masseteric supercharge bypass may be an acceptable surgical technique to restore muscle function in potentially higher risk cases.
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Affiliation(s)
- Petr Vachata
- Department of Neurosurgery, Masaryk Hospital, J. E, Purkyně University, Socialni pece 3316/12A, 40113, Usti nad Labem, Czech Republic.
- Department of Neurosurgery, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 30100, Pilsen, Czech Republic.
| | - Stepanka Brusakova
- Department of Neurology, Masaryk Hospital, Socialni pece 3316/12A, 40113, Usti nad Labem, Czech Republic
| | - Jan Lodin
- Department of Neurosurgery, Masaryk Hospital, J. E, Purkyně University, Socialni pece 3316/12A, 40113, Usti nad Labem, Czech Republic
| | - Martin Sames
- Department of Neurosurgery, Masaryk Hospital, J. E, Purkyně University, Socialni pece 3316/12A, 40113, Usti nad Labem, Czech Republic
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Abstract
Nerve transfer surgery involves using a working, functional nerve with an expendable or duplicated function as a donor to supply axons and restore function to an injured recipient nerve. Nerve transfers were originally popularized for the restoration of motor function in patients with peripheral nerve injuries. However, more recently, novel uses of nerve transfers have been described, including nerve transfers for sensory reinnervation, nerve transfers for spinal cord injury and stroke patients, supercharge end-to-side nerve transfers, and targeted muscle reinnervation for the prevention and treatment of postamputation neuroma pain. The uses for nerve transfers and the patient populations that can benefit from nerve transfer surgery continue to expand. Awareness about these novel uses of nerve transfers among the medical community is important in order to facilitate evaluation and treatment of these patients by peripheral nerve specialists. A lack of knowledge of these techniques continues to be a major barrier to more widespread implementation.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, R293, Stanford, California, 94305, USA.
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