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Zhang J, Tao J, Cheng H, Liu H, Wu W, Dong Y, Liu X, Gou M, Yang S, Xu J. Nerve transfer with 3D-printed branch nerve conduits. BURNS & TRAUMA 2022; 10:tkac010. [PMID: 35441080 PMCID: PMC9012979 DOI: 10.1093/burnst/tkac010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 02/15/2022] [Accepted: 02/27/2022] [Indexed: 02/05/2023]
Abstract
Background Nerve transfer is an important clinical surgical procedure for nerve repair by the coaptation of a healthy donor nerve to an injured nerve. Usually, nerve transfer is performed in an end-to-end manner, which will lead to functional loss of the donor nerve. In this study, we aimed to evaluate the efficacy of 3D-printed branch nerve conduits in nerve transfer. Methods Customized branch conduits were constructed using gelatine-methacryloyl by 3D printing. The nerve conduits were characterized both in vitro and in vivo. The efficacy of 3D-printed branch nerve conduits in nerve transfer was evaluated in rats through electrophysiology testing and histological evaluation. Results The results obtained showed that a single nerve stump could form a complex nerve network in the 3D-printed multibranch conduit. A two-branch conduit was 3D printed for transferring the tibial nerve to the peroneal nerve in rats. In this process, the two branches were connected to the distal tibial nerve and peroneal nerve. It was found that the two nerves were successfully repaired with functional recovery. Conclusions It is implied that the two-branch conduit could not only repair the peroneal nerve but also preserve partial function of the donor tibial nerve. This work demonstrated that 3D-printed branch nerve conduits provide a potential method for nerve transfer.
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Affiliation(s)
- Jing Zhang
- Department of Neurosurgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Jie Tao
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Hao Cheng
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Haofan Liu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Wenbi Wu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Yinchu Dong
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Xuesong Liu
- Department of Neurosurgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Maling Gou
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
| | - Siming Yang
- Key Laboratory of Wound Repair and Regeneration of PLA, Chinese PLA General Hospital, Medical College of PLA, Beijing 100853, P.R. China
| | - Jianguo Xu
- Department of Neurosurgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu 610041, P.R. China
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Luft M, Klepetko J, Muceli S, Ibáñez J, Tereshenko V, Festin C, Laengle G, Politikou O, Maierhofer U, Farina D, Aszmann OC, Bergmeister KD. Proof of concept for multiple nerve transfers to a single target muscle. eLife 2021; 10:e71312. [PMID: 34596042 PMCID: PMC8530510 DOI: 10.7554/elife.71312] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Surgical nerve transfers are used to efficiently treat peripheral nerve injuries, neuromas, phantom limb pain, or improve bionic prosthetic control. Commonly, one donor nerve is transferred to one target muscle. However, the transfer of multiple nerves onto a single target muscle may increase the number of muscle signals for myoelectric prosthetic control and facilitate the treatment of multiple neuromas. Currently, no experimental models are available. This study describes a novel experimental model to investigate the neurophysiological effects of peripheral double nerve transfers to a common target muscle. In 62 male Sprague-Dawley rats, the ulnar nerve of the antebrachium alone (n=30) or together with the anterior interosseus nerve (n=32) was transferred to reinnervate the long head of the biceps brachii. Before neurotization, the motor branch to the biceps' long head was transected at the motor entry point. Twelve weeks after surgery, muscle response to neurotomy, behavioral testing, retrograde labeling, and structural analyses were performed to assess reinnervation. These analyses indicated that all nerves successfully reinnervated the target muscle. No aberrant reinnervation was observed by the originally innervating nerve. Our observations suggest a minimal burden for the animal with no signs of functional deficit in daily activities or auto-mutilation in both procedures. Furthermore, standard neurophysiological analyses for nerve and muscle regeneration were applicable. This newly developed nerve transfer model allows for the reliable and standardized investigation of neural and functional changes following the transfer of multiple donor nerves to one target muscle.
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Affiliation(s)
- Matthias Luft
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Johanna Klepetko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Silvia Muceli
- Department of Electrical Engineering, Chalmers University of TechnologyGothenburgSweden
| | - Jaime Ibáñez
- Department of Bioengineering, Imperial College LondonLondonUnited Kingdom
- Department of Clinical and Movement Neuroscience, University College London, LondonLondonUnited Kingdom
- BSICoS Group, IIS Aragón, Universidad de ZaragozaZaragozaSpain
| | - Vlad Tereshenko
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Christopher Festin
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Gregor Laengle
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Olga Politikou
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Udo Maierhofer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
| | - Dario Farina
- Department of Bioengineering, Imperial College LondonLondonUnited Kingdom
- Department of Clinical and Movement Neuroscience, University College London, LondonLondonUnited Kingdom
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
| | - Konstantin Davide Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of ViennaViennaAustria
- Center for Biomedical Research, Medical University of ViennaViennaAustria
- Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and ReconstructiveSurgery, University Hospital St. PoeltenSt. PoeltenAustria
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3
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Bergmeister KD, Aman M, Muceli S, Vujaklija I, Manzano-Szalai K, Unger E, Byrne RA, Scheinecker C, Riedl O, Salminger S, Frommlet F, Borschel GH, Farina D, Aszmann OC. Peripheral nerve transfers change target muscle structure and function. SCIENCE ADVANCES 2019; 5:eaau2956. [PMID: 30613770 PMCID: PMC6314825 DOI: 10.1126/sciadv.aau2956] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 11/26/2018] [Indexed: 05/05/2023]
Abstract
Selective nerve transfers surgically rewire motor neurons and are used in extremity reconstruction to restore muscle function or to facilitate intuitive prosthetic control. We investigated the neurophysiological effects of rewiring motor axons originating from spinal motor neuron pools into target muscles with lower innervation ratio in a rat model. Following reinnervation, the target muscle's force regenerated almost completely, with the motor unit population increasing to 116% in functional and 172% in histological assessments with subsequently smaller muscle units. Muscle fiber type populations transformed into the donor nerve's original muscles. We thus demonstrate that axons of alternative spinal origin can hyper-reinnervate target muscles without loss of muscle force regeneration, but with a donor-specific shift in muscle fiber type. These results explain the excellent clinical outcomes following nerve transfers in neuromuscular reconstruction. They indicate that reinnervated muscles can provide an accurate bioscreen to display neural information of lost body parts for high-fidelity prosthetic control.
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Affiliation(s)
- Konstantin D. Bergmeister
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Martin Aman
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Silvia Muceli
- Department of Bioengineering, Imperial College London, London, UK
- Clinic for Trauma Surgery, Orthopaedic Surgery and Plastic Surgery–Research Department of Neurorehabilitation Systems, University Medical Center Göttingen, Göttingen, Germany
| | - Ivan Vujaklija
- Department of Bioengineering, Imperial College London, London, UK
| | - Krisztina Manzano-Szalai
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Ewald Unger
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Ruth A. Byrne
- Division of Rheumatology, Clinic for Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Clemens Scheinecker
- Division of Rheumatology, Clinic for Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Otto Riedl
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Salminger
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Gregory H. Borschel
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Dario Farina
- Department of Bioengineering, Imperial College London, London, UK
| | - Oskar C. Aszmann
- CD Laboratory for the Restoration of Extremity Function, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Vienna, Austria
- Corresponding author.
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Transfer of the Pronator Quadratus Motor Branch for Wrist Extension Reconstruction in Brachial Plexus Palsy. Plast Reconstr Surg 2012. [DOI: 10.1097/prs.0b013e31826d16cf] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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5
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Bertelli JA, Ghizoni MF. Concepts of nerve regeneration and repair applied to brachial plexus reconstruction. Microsurgery 2006; 26:230-44. [PMID: 16586502 DOI: 10.1002/micr.20234] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Brachial plexus injury is a serious condition that usually affects young adults. Progress in brachial plexus repair is intimately related to peripheral nerve surgery, and depends on clinical and experimental studies. We review the rat brachial plexus as an experimental model, together with its behavioral evaluation. Techniques to repair nerves, such as neurolysis, nerve coaptation, nerve grafting, nerve transfer, fascicular transfer, direct muscle neurotization, and end-to-side neurorraphy, are discussed in light of the authors' experimental studies. Intradural repair of the brachial plexus by graft implants into the spinal cord and motor rootlet transfer offer new possibilities in brachial plexus reconstruction. The clinical experience of intradural repair is presented. Surgical planning in root rupture or avulsion is proposed. In total avulsion, the authors are in favor of the reconstruction of thoraco-brachial and abdomino-antebrachial grasping, and on the transfer of the brachialis muscle to the wrist extensors if it is reinnervated. Surgical treatment of painful conditions and new drugs are also discussed.
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Bertelli JA, Taleb M, Mira JC, Ghizoni MF. Functional recovery improvement is related to aberrant reinnervation trimming. A comparative study using fresh or predegenerated nerve grafts. Acta Neuropathol 2006; 111:601-9. [PMID: 16718355 DOI: 10.1007/s00401-005-0005-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Revised: 09/13/2005] [Accepted: 09/13/2005] [Indexed: 11/24/2022]
Abstract
Experimentally predegenerated nerve grafts have been demonstrated to improve recovery. In a 12 month-long study, we compared the degree of recovery of conventional and predegenerated grafts in rat median nerve repair. To induce predegeneration the ulnar donor nerve was crushed and grafting to the median nerve was performed 2 weeks later. The day of recovery and the improvement of finger flexion strength were studied by the grasping test. At 3, 6, 9, and 12 months after surgery retrograde labeling studies and flexor carpi radialis muscle ATPase histochemistry were performed. In the predegenerated grafts, the recovery of finger flexion occurred 19.6+/-1.5 days after surgery and was significantly faster than that in the conventional group. Twelve months after surgery, a similar rate of 85% of grasping strength recovery in relation to the normal control rats was demonstrated for the conventional and predegenerated grafts. After grafting, a larger number of motoneurons, compared to the normal controls, were retrograde labeled in the median nerve. This surplus of retrograde labeled motoneurons in the predominantly sensory branch of the median nerve represented misdirected motor fibers. There was a time-related decrease in the number of labeled motoneurons, which correlated to functional grasping strength recovery. Muscle reinnervation induced a predominance of type I over type II muscle fibers. Forty percent of type I fibers were grouped indicating that collateral sprouting plays a prominent role during muscle reinnervation. Regeneration in predegenerated grafts was faster but the final rate of recovery was similar to conventional grafts.
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Affiliation(s)
- Jayme Augusto Bertelli
- Centro de Ciências Biológicas e da Saúde (CCBS), Universidade do Sul de Santa Catarina (Unisul), Tubarão, and Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, SC, Brazil.
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7
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Bertelli JA, Ghizoni MF. Contralateral motor rootlets and ipsilateral nerve transfers in brachial plexus reconstruction. J Neurosurg 2004; 101:770-8. [PMID: 15540915 DOI: 10.3171/jns.2004.101.5.0770] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. The goal of this study was to evaluate outcomes in patients with brachial plexus avulsion injuries who underwent contralateral motor rootlet and ipsilateral nerve transfers to reconstruct shoulder abduction/external rotation and elbow flexion.
Methods. Within 6 months after the injury, 24 patients with a mean age of 21 years underwent surgery in which the contralateral C-7 motor rootlet was transferred to the suprascapular nerve by using sural nerve grafts. The biceps motor branch or the musculocutaneous nerve was repaired either by an ulnar nerve fascicular transfer or by transfer of the 11th cranial nerve or the phrenic nerve. The mean recovery in abduction was 90° and 92° in external rotation. In cases of total palsy, only two patients recovered external rotation and in those cases mean external rotation was 70°. Elbow flexion was achieved in all cases. In cases of ulnar nerve transfer, the muscle scores were M5 in one patient, M4 in six patients, and M3+ in five patients. Elbow flexion repair involving the use of the 11th cranial nerve resulted in a score of M3+ in five patients and M4 in two patients. After surgery involving the phrenic nerve, two patients received a score of M3+ and two a score of M4. Results were clearly better in patients with partial lesions and in those who were shorter than 170 cm (p < 0.01). The length of the graft used in motor rootlet transfers affected only the recovery of external rotation. There was no permanent injury at the donor sites.
Conclusions. Motor rootlet transfer represents a reliable and potent neurotizer that allows the reconstruction of abduction and external rotation in partial injuries.
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Affiliation(s)
- Jayme Augusto Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Brazil.
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8
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Chuang TY, Huang MC, Chen KC, Chang YC, Yen YS, Lee LS, Cheng H. Forelimb muscle activity following nerve graft repair of ventral roots in the rat cervical spinal cord. Life Sci 2002; 71:487-96. [PMID: 12052433 DOI: 10.1016/s0024-3205(02)01623-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Current research on the cellular mechanisms of nerve regeneration suggests the application of nerve growth factors at the repair sites to be beneficial. To test the effectiveness of this approach, we performed transections of the C6 and C7 ventral rootlets from their original sites in the spinal cord of 18 rats. We investigated the electrophysiological changes in three groups of rats operated on by different repair strategies. Six rats comprised the control group (G1). In the other 12 rats, 24 rootlets were implanted into the spinal cord by means of an intercostal nerve graft through the pia mater immediately after transection. Six rats (G2) had fibrin glue applied at the incision. The last 6 rats (G3) had grafts with acidic fibroblast growth factor (aFGF) added to the fibrin glue. The rats' functional recovery was evaluated electrophysiologically at 6 weeks and 6 months after the operation. Needle electromyography showed profound fibrillation potentials (Daube's scoring system) in the deltoid, biceps, and triceps of the operated forelimbs in all groups 6 weeks after the operation. After 6 months, there was a significant decrease in the amount of fibrillation potentials in all groups (G1, G2 and G3, p < 0.0001, 0.0001, 0.0009, respectively, generalized estimating equation, repeated measures) and a significantly high probability for motor units present in sampled muscles of G2 and G3 as compared to G1 (log odds ratio in G2 = 51.8316, G3 = 57.4262, generalized estimating equation). We conclude that several cervical roots can regenerate through intercostal nerve grafts applied using fibrin glue. Adding aFGF may increase the efficacy of sprouting.
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Affiliation(s)
- Tien-Yow Chuang
- Neurophysiologic Laboratory, Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital and National Yang-Ming University, Taiwan
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Ramer MS, McMahon SB, Priestley JV. Axon regeneration across the dorsal root entry zone. PROGRESS IN BRAIN RESEARCH 2001; 132:621-39. [PMID: 11545025 DOI: 10.1016/s0079-6123(01)32107-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- M S Ramer
- Department of Neuroscience, St. Bartholomew's and the Royal London School of Medicine and Dentistry, Queen Mary University of London, Mile End Road, London E1 4NS, UK.
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Bertelli JA, Guizoni MF, Dos Santos AR, Calixto JB, Duarte HE. Cross-chest radial nerve transfer in brachial plexus injuries. Experimental and anatomical basis. CHIRURGIE DE LA MAIN 2000; 18:122-30; discussion 131. [PMID: 10855310 DOI: 10.1016/s0753-9053(99)80065-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Brachial plexus avulsion injuries are devastating injuries to the upper limb, and nerve transfer remains the only option in reconstruction. Despite the encouraging results concerning recovery of shoulder and elbow function, no option is available for treatment of the paralytic hand. In rats, we sectioned the radial nerve in the elbow region and transferred it across the chest to reinnervate the lesioned contralateral medial cord of the brachial plexus. Rats were then evaluated for motor and sensory recovery, electrophysiologically, behaviorally and morphologically. Forepaw functional recovery was estimated to be 90%. In cadavers, the radial nerve and profunda brachii artery were dissected. It was observed that the radial nerve vascularized by the profunda brachii artery was able to reach the contralateral brachial plexus distal to the shoulder region without nerve grafts. After sectioning the radial nerve, sensory loss is minimal and motor palsy can be easily restored by tendon transfers. The results of tendon transfer for radial nerve palsy are better than for any other nerve. Cross-chest radial nerve transfer might be of clinical interest in the reconstruction of hand function in entire injury to the brachial plexus.
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Affiliation(s)
- J A Bertelli
- Joana de Gusmão Children's Hospital, Florianópolis SC, Brazil
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Bertelli JA, Ghizoni MF. A surgical approach for concomitant spinal cord and brachial plexus surgery: an anatomical study. CHIRURGIE DE LA MAIN 2000; 17:159-64. [PMID: 10855283 DOI: 10.1016/s0753-9053(98)80011-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Spinal cord surgery is not the current treatment for brachial plexus avulsion injuries. However, several experimental and a few clinical cases have been reported with promising results. This surgical strategy in the near future, might prove to be useful. Different simultaneous anatomical approaches to the brachial plexus and spinal cord were studied in attempt to discover the best route to be used in the surgical reconstruction of avulsion lesions of the brachial plexus by spinal cord surgery. Eleven fresh subjects were used to compare: a) simultaneous dorsal approaches to the brachial plexus and spinal cord, b) the dorsal approach to the spinal cord and the anterior approach to the brachial plexus, c) a dorsal approach to the spinal cord combined with a dorsal approach through the triceps muscle to the terminal branches of the brachial plexus and d) a purely anterior approach to the spinal cord and brachial plexus. During the study, special attention was paid to the length of the grafts needed for repair, the possibility of entire exposure of the brachial plexus and the possibility of performing concomitant nerve transfers. As a result of the anatomical findings, we would suggest a dorsal approach to the spinal cord, suprascapular nerve and sometimes to the axillary nerve, combined with an anterior exposure to the brachial plexus in order to have the whole plexus explored and routine simultaneous nerve transfers performed. In selected cases, with limited root injuries, the dorsal approach to the brachial plexus and spinal cord and the anterior approach to the brachial plexus and spinal cord might be of interest.
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Affiliation(s)
- J A Bertelli
- Hospital Infantil Joana de Gusmao, Florianopolis, SC, Brazil
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Haninec P, Dubový P, Houst'ava L, Stejskal L. Acellular nerve graft re-seeded by Schwann cells migrating from the nerve stump can stimulate spinal motoneurons for functional reinnervation of the rat muscle. Ann Anat 2000; 182:123-31. [PMID: 10755179 DOI: 10.1016/s0940-9602(00)80069-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The acellular nerve graft was utilised to restore a functional reinnervation of the biceps brachii muscle from the motoneuron pool of the cervical spinal cord. The musculocutaneous nerve stump was sutured to an acellular nerve graft, the opposite end of which was inserted into the cervical spinal cord cranial to the avulsed C5 ventral root. The acellular nerve graft was repopulated by Schwann cells heavily immunostained for NGFr within 90 days. The Schwann cells migrating from the nerve stump reached the spinal cord grey matter, where they stimulated the motoneurons to send axonal sprouts. The functional reinnervation of the biceps brachii muscle was assessed by means of the behavioural (grooming) test and EMG, the presence of myelinated and unmyelinated axons was demonstrated by light and electron microscopy. The axonal reconnection of the musculocutaneous nerve stump was verified by horseradish peroxidase retrograde labelling of the spinal motoneurons. Moreover, the motoneurons on the operated side of the C5 spinal segment displayed increased immunostaining for GAP-43 in comparison to the contralateral side, whereas the pattern of AChE histochemical reaction was similar on both the operated and contralateral side, of the C5 segment 150 days after acellular graft implantation. The regenerated axons bridged a 4-cm long originally acellular nerve graft to reach and reinnervate the biceps brachii muscle. The reinnervation of the neuromuscular junctions was morphologically determined by immunofluorescence for neurofilaments. The number of myelinated axons in the acellular nerve graft was significantly higher than those growing over the cellular graft, but their diameter was smaller. The results of experiments presented here demonstrate functional recovery of the biceps muscle reinnervation through the acellular nerve graft repopulated by migrating Schwann cells. The process of reinnervation by acellular nerve graft is however delayed and worse in comparison with the cellular graft.
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Affiliation(s)
- P Haninec
- Division of Neurosurgery, 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
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13
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Bertelli JA, Ghizoni MF. Selective motor hyperreinnervation by using contralateral C-7 motor rootlets in the reconstruction of an avulsion injury of the brachial plexus. Case report. J Neurosurg 1999; 90:1133-6. [PMID: 10350263 DOI: 10.3171/jns.1999.90.6.1133] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Brachial plexus avulsion injuries are a clinical challenge. In recent experimental studies the authors have demonstrated the high degree of muscle reinnervation attained when a C-4 motor rootlet was directly connected to the musculocutaneous nerve. This degree of reinnervation was attributed to the good chance that a muscle fiber can be reinnervated by a motor fiber when the number of regenerating motor neurons is increased and when competitive sensory fibers are excluded from the process. The authors present the first clinical case in which this phenomenon has been observed. This 26-year-old man, who was involved in an automobile accident, presented with an upper brachial plexus avulsion, for which he underwent operation 4 months later. The axillary and suprascapular nerves were directly surgically connected to the motor rootlets of the C-7 contralateral root by using two cables of sural nerve graft. Two years postsurgery, the patient was able to perform shoulder abduction of 120 degrees and hold an 800-g weight at 90 degrees. These results are encouraging, and in selected patients motor rootlet transfer might prove to be a useful surgical strategy.
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Affiliation(s)
- J A Bertelli
- Joana de Gusmão Children's Hospital, Florianópolis, Santa Catarina, Brazil
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