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Tang CQY, Yam AKT, Chew EM. Letter to the Editor-in-Chief. J Hand Surg Eur Vol 2024; 49:922-923. [PMID: 38488620 DOI: 10.1177/17531934241238143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Camelia Qian Ying Tang
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
| | | | - Ee Ming Chew
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
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2
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Lysak A, Farnebo S, Geuna S, Dahlin LB. Muscle preservation in proximal nerve injuries: a current update. J Hand Surg Eur Vol 2024; 49:773-782. [PMID: 38819009 DOI: 10.1177/17531934231216646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Optimal recovery of muscle function after proximal nerve injuries remains a complex and challenging problem. After a nerve injury, alterations in the affected muscles lead to atrophy, and later degeneration and replacement by fat-fibrous tissues. At present, several different strategies for the preservation of skeletal muscle have been reported, including various sets of physical exercises, muscle massage, physical methods (e.g. electrical stimulation, magnetic field and laser stimulation, low-intensity pulsed ultrasound), medicines (e.g. nutrients, natural and chemical agents, anti-inflammatory and antioxidants, hormones, enzymes and enzyme inhibitors), regenerative medicine (e.g. growth factors, stem cells and microbiota) and surgical procedures (e.g. supercharge end-to-side neurotization). The present review will focus on methods that aimed to minimize the damage to muscles after denervation based on our present knowledge.
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Affiliation(s)
- Andrii Lysak
- Institute of Traumatology and Orthopedics of National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - Simon Farnebo
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, Linköping, Sweden
| | - Stefano Geuna
- Department of Clinical and Biological Sciences; Neuroscience Institute Cavalieri Ottolenghi, University of Torino, Torino, Italy
| | - Lars B Dahlin
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
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3
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McMorrow LA, Czarnecki P, Reid AJ, Tos P. Current perspectives on peripheral nerve repair and management of the nerve gap. J Hand Surg Eur Vol 2024; 49:698-711. [PMID: 38603601 DOI: 10.1177/17531934241242002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.
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Affiliation(s)
- Liam A McMorrow
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Piotr Czarnecki
- Department of Traumatology, Orthopaedics and Hand Surgery, Poznań University of Medical Sciences, Poznań, Poland
| | - Adam J Reid
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Pierluigi Tos
- Azienda Socio Sanitaria Territoriale Gaetano Pini, Milan, Italy
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Thorkildsen RD, Kleggetveit IP, Thu F, Madsen LM, Bolstad BJ, Røkkum M. Supercharging of the ulnar nerve: clinical and neurophysiological assessment at 2 years for nine proximal injuries. J Hand Surg Eur Vol 2024:17531934231226174. [PMID: 38235708 DOI: 10.1177/17531934231226174] [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: 01/19/2024]
Abstract
LEVEL OF EVIDENCE II.
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Affiliation(s)
- Rasmus Dehli Thorkildsen
- Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Inge Petter Kleggetveit
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Frode Thu
- Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Lise Maurstad Madsen
- Section for Orthopaedic Rehabilitation, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørg Johanna Bolstad
- Section for Orthopaedic Rehabilitation, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Magne Røkkum
- Upper Extremity and Microsurgical Unit, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
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Miller TA, Ross DC. Sciatic and tibial neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:165-181. [PMID: 38697738 DOI: 10.1016/b978-0-323-90108-6.00003-x] [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
The sciatic nerve is the body's largest peripheral nerve. Along with their two terminal divisions (tibial and fibular), their anatomic location makes them particularly vulnerable to trauma and iatrogenic injuries. A thorough understanding of the functional anatomy is required to adequately localize lesions in this lengthy neural pathway. Proximal disorders of the nerve can be challenging to precisely localize among a range of possibilities including lumbosacral pathology, radiculopathy, or piriformis syndrome. A correct diagnosis is based upon a thorough history and physical examination, which will then appropriately direct adjunctive investigations such as imaging and electrodiagnostic testing. Disorders of the sciatic nerve and its terminal branches are disabling for patients, and expert assessment by rehabilitation professionals is important in limiting their impact. Applying techniques established in the upper extremity, surgical reconstruction of lower extremity nerve dysfunction is rapidly improving and evolving. These new techniques, such as nerve transfers, require electrodiagnostic assessment of both the injured nerve(s) as well as healthy, potential donor nerves as part of a complete neurophysiological examination.
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Affiliation(s)
- Thomas A Miller
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, St. Joseph's Health Care, Parkwood Institute, London, ON, Canada.
| | - Douglas C Ross
- Division of Plastic Surgery, Schulich School of Medicine and Dentistry, Western University, St. Joseph's Health Care, Roth McFarlane Hand and Upper Limb Centre, London, ON, Canada
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Kulenkampff C, Duraku LS, George S, Power D. Supercharged End-to-Side Nerve Transfer for Ulnar Neuropathy: Redefining Nomenclature and Recommendations for Standardisation of Surgical Technique Description. Cureus 2023; 15:e48660. [PMID: 37954629 PMCID: PMC10639114 DOI: 10.7759/cureus.48660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 11/14/2023] Open
Abstract
Supercharged end-to-side (SETS) nerve transfers have been described as a treatment option for ulnar neuropathy, however, there is inconsistency in the nomenclature used to describe the microsurgical technique. The purpose of this article is to systematically review the available literature on the SETS nerve transfer technique and to provide an overview of the technical variations to facilitate standardisation of surgical method. A literature review was performed through PubMed, MEDLINE, and Ovid databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that reported surgical technique of anterior interosseous nerve (AIN) to ulnar nerve SETS transfer were included. Studies were excluded when not referencing SETS/reverse end-to-side (RETS) nerve transfers, studies referencing nerve transfers other than AIN to motor fascicle bundle of the ulnar nerve (MUN), animal studies, and studies not reporting technique. Of the 168 studies found, 14 articles were included. In five articles, distal visualisation of the MUN in Guyon's canal was specifically cited. In the four studies that commented on donor preparation, sharp neurectomy proximal to the AIN branching point was undertaken. Recipient preparation was commented on in seven of the included studies. Two studies referred to an epineurial window only while five specifically recommended a perineurial window. Coaptation site was specified in four studies and all studies used sutures for coaptation, with four articles stipulating that 9-0 nylon was used. Additionally, fibrin glue was used in conjunction with suture technique in four studies. Consistency in nomenclature used to describe SETS microsurgical technique is needed before case series measuring outcome can be reliably interpreted. This review allowed for the development of suggestions for standardisation of nomenclature and minimal reporting requirements when describing SETS technique. Standardisation of technique will allow for reproducibility and facilitate future evaluations of outcome in prospective randomised control trials.
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Affiliation(s)
- Chane Kulenkampff
- Peripheral Nerve Surgery Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | - Liron S Duraku
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centers, Amsterdam, NLD
- Peripheral Nerve Surgery Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | - Samuel George
- Peripheral Nerve Surgery Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
| | - Dominic Power
- Peripheral Nerve Surgery Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, GBR
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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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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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Chen VY, Gonzales LP, Johnston TR, Steward O, Gupta R. Preoperative Muscle Biopsy to Assess Motor End Plate Integrity as a Predictor for Successful Nerve Transfer: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00042. [PMID: 36795913 DOI: 10.2106/jbjs.cc.22.00569] [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: 06/18/2023]
Abstract
CASE A 60-year-old right-hand-dominant man was referred for persistent right deltoid weakness, lateral shoulder numbness, and severe functional deficit 3 months after undergoing proximal humerus open reduction and internal fixation with plate and fibular strut allograft. Deltoid muscle biopsy demonstrated motor end plate (MEP) degeneration. After partial radial-to-axillary nerve transfer, repeat deltoid muscle biopsy revealed successful regeneration of MEPs with reinnervation of deltoid confirmed with postnerve transfer electromyography. CONCLUSION Selective nerve transfer can successfully rescue a denervated target muscle from further degeneration by restoration of healthy MEPs.
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Affiliation(s)
- Vivian Y Chen
- Department of Orthopaedic Surgery, University of California, Irvine, California
| | - Luigi P Gonzales
- Department of Orthopaedic Surgery, University of California, Irvine, California
| | - Tyler R Johnston
- Department of Orthopaedic Surgery, University of California, Irvine, California
| | - Oswald Steward
- Reeve-Irvine Research Center, University of California, Irvine, California
| | - Ranjan Gupta
- Department of Orthopaedic Surgery, University of California, Irvine, California
- Reeve-Irvine Research Center, University of California, Irvine, California
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Bazarek S, Johnston BR, Sten M, Mandeville R, Eggan K, Wainger BJ, Brown JM. Spinal motor neuron transplantation to enhance nerve reconstruction strategies: Towards a cell therapy. Exp Neurol 2022; 353:114054. [PMID: 35341748 DOI: 10.1016/j.expneurol.2022.114054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 11/19/2022]
Abstract
Nerve transfers have become a powerful intervention to restore function following devastating paralyzing injuries. A major limitation to peripheral nerve repair and reconstructive strategies is the progressive, fibrotic degeneration of the distal nerve and denervated muscle, eventually precluding recovery of these targets and thus defining a time window within which reinnervation must occur. One proven strategy in the clinic has been the sacrifice and transfer of an adjacent distal motor nerve to provide axons to occupy, and thus preserve (or "babysit"), the target muscle. However, available nearby nerves are limited in severe brachial plexus or spinal cord injury. An alternative and novel proposition is the transplantation of spinal motor neurons (SMNs) derived from human induced pluripotent stem cells (iPSCs) into the target nerve to extend their axons to occupy and preserve the targets. These cells could potentially be delivered through minimally invasive or percutaneous techniques. Several reports have demonstrated survival, functional innervation, and muscular preservation following transplantation of SMNs into rodent nerves. Advances in the generation, culture, and differentiation of human iPSCs now offer the possibility for an unlimited supply of clinical grade SMNs. This review will discuss the previous reports of peripheral SMN transplantation, outline key considerations, and propose next steps towards advancing this approach to clinic. Stem cells have garnered great enthusiasm for their potential to revolutionize medicine. However, this excitement has often led to premature clinical studies with ill-defined cell products and mechanisms of action, particularly in spinal cord injury. We believe the peripheral transplantation of a defined SMN population to address neuromuscular degeneration will be transformative in augmenting current reconstructive strategies. By thus removing the current barriers of time and distance, this strategy would dramatically enhance the potential for reconstruction and functional recovery in otherwise hopeless paralyzing injuries. Furthermore, this strategy may be used as a permanent axon replacement following destruction of lower motor neurons and would enable exogenous stimulation options, such as pacing of transplanted SMN axons in the phrenic nerve to avoid mechanical ventilation in high cervical cord injury or amyotrophic lateral sclerosis.
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Affiliation(s)
- Stanley Bazarek
- Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Benjamin R Johnston
- Department of Neurosurgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, United States of America; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Margaret Sten
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Ross Mandeville
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Kevin Eggan
- BioMarin Pharmaceutical Inc., San Rafael, CA, United States of America
| | - Brian J Wainger
- Departments of Neurology and Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Justin M Brown
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
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