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Koliarakis I, Manatakis DK, Tsitsipanis C, Drakonaki E, Tsamandouras I, Tsiaoussis J. Spinal accessory nerve anatomy in the posterior cervical triangle: A systematic review with meta-analysis. Clin Anat 2024; 37:130-139. [PMID: 37767816 DOI: 10.1002/ca.24119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/10/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
This study aimed to investigate the anatomy of the spinal accessory nerve (SAN) in the posterior cervical triangle, especially in relation to adjacent anatomical landmarks, along with a systematic review of the current literature with a meta-analysis of the data. Overall, 22 cadaveric and three prospective intraoperative studies, with a total of 1346 heminecks, were included in the analysis. The major landmarks relevant to the entry of the SAN at the posterior border of the SCM muscle (PBSCM) were found to be the mastoid apex, the great auricular point (GAP), the nerve point (NP), and the point where the PBSCM meets the upper border of the clavicle. The SAN was reported to enter the posterior cervical triangle above GAP in 100% of cases and above NP in most cases (97.5%). The mean length of the SAN along its course from the entry point to its exit point from the posterior triangle of the neck was 4.07 ± 1.13 cm. The SAN mainly gave off 1 or 2 branches (32.5% and 31%, respectively) and received either no branches or one branch in most cases (58% and 23%, respectively) from the cervical plexus during its course in the posterior cervical triangle. The major landmarks relevant to the entry of the SAN at the anterior border of the TPZ muscle (ABTPZ) were found to be the point where the ABTPZ meets the upper border of the clavicle and the midpoint of the clavicle, along with the mastoid apex, the acromion, and the transverse distance of the SAN exit point to the PBSCM. The results of the present meta-analysis will be helpful to surgeons operating in the posterior cervical triangle, aiding the avoidance of the iatrogenic injury of the SAN.
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Affiliation(s)
- Ioannis Koliarakis
- Department of Anatomy, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | | | - Christos Tsitsipanis
- Department of Anatomy, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Elena Drakonaki
- Department of Anatomy, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Ioannis Tsamandouras
- Department of Otorhinolaryngology - Head and Neck Surgery, University General Hospital of Heraklion, Heraklion, Crete, Greece
| | - John Tsiaoussis
- Department of Anatomy, School of Medicine, University of Crete, Heraklion, Crete, Greece
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Filipov I, Chirila L, Bolognesi F, Sandulescu M, Drafta S, Cristache CM. Research trends and perspectives on immediate facial reanimation in radical parotidectomy (Review). Biomed Rep 2023; 19:81. [PMID: 37881603 PMCID: PMC10594070 DOI: 10.3892/br.2023.1663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/05/2023] [Indexed: 10/27/2023] Open
Abstract
For patients diagnosed with advanced malignant parotid tumour, radical parotidectomy with facial nerve sacrifice is part of the treatment. Multiple surgical techniques have been developed to cure facial paralysis in order to restore the function and aesthetics of the face. Despite the large number of publications over time on facial nerve reanimation, a consensus on the timing of the procedure or the donor graft selection has remained to be established. Therefore, the aim of the present study was to conduct a bibliometric analysis to identify and analyse scientific publications on the reconstruction of the facial nerve of patients who underwent radical parotidectomy with facial nerve sacrifice. The analysis on the topic was conducted using the built-in tool of the Scopus database and VOSviewer software. The first 100 most cited articles were separately reviewed to address the aim of the study. No consensus was found regarding the recommended surgical techniques for facial nerve reanimation. The most used donor cranial nerves for transfer included the following: Masseteric branch of the V nerve, contralateral VII nerve with cross-face graft, the XI nerve and the XII nerve. The best timing of surgery is also controversial depending on pre-exiting pathology and degree of nerve degeneration. However, most of the clinical experience suggests facial nerve restoration immediately after the ablative procedure to reduce complications and improve patients' quality of life.
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Affiliation(s)
- Iulian Filipov
- Doctoral School, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Maxillofacial Surgery, ‘Queen Maria’ Military Emergency Hospital, 500007 Brasov, Romania
| | - Lucian Chirila
- Department of Oral and Maxillofacial Surgery, ‘Carol Davila’ University of Medicine and Pharmacy, 010221 Bucharest, Romania
| | - Federico Bolognesi
- Oral and Maxillo-Facial Surgery Unit, IRCCS Policlinico di Sant'Orsola, I-40138 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, I-40100 Bologna, Italy
| | - Mihai Sandulescu
- Department of Implant Prosthetic Therapy, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 010221 Bucharest, Romania
| | - Sergiu Drafta
- Department of Fixed Dental Prosthetics and Occlusion, Faculty of Dental Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 010221 Bucharest, Romania
| | - Corina Marilena Cristache
- Department of Dental Techniques, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
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Shin AY, Bishop AT, Loosbroch MF, Spinner RJ. A multidisciplinary approach to the management of brachial plexus injuries: experience from the Mayo Clinic over 100 years. J Hand Surg Eur Vol 2022; 47:1103-1113. [PMID: 35833214 DOI: 10.1177/17531934221110733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A multidisciplinary brachial plexus clinic has been a relatively new concept, offering different surgical speciality perspectives on the treatment of brachial plexus injuries. The resulting collaborative effort has proven to be greater than the sum of its parts. In this review, the history, philosophy of care, development/implementation and impact of a creation of a multidisciplinary brachial plexus team at the Mayo Clinic are detailed.
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Affiliation(s)
- Alexander Y Shin
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen T Bishop
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle F Loosbroch
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert J Spinner
- Department of Orthopedic Surgery, Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
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Transfer of a C7 Fascicle for the Pectoralis Major to the Suprascapular Nerve: A 3-Year Follow-Up Patient Series. Plast Reconstr Surg 2022; 149:672-675. [PMID: 35196685 DOI: 10.1097/prs.0000000000008851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In patients with C5-C6 brachial plexus injury, spinal accessory nerve transfer to the suprascapular nerve is usually performed for the restoration of shoulder abduction. In order to minimize donor deficits, we transferred one fascicle of the ipsilateral C7 root, dedicated to the pectoralis major muscle, to the suprascapular nerve. METHODS Ten patients with a mean age of 33 years (range, 19 to 51 years) were operated on at a mean delay of 4 months after their trauma (range, 2 to 7 months). Patients had C5-C6 brachial plexus palsy with avulsed roots on spinal magnetic resonance imaging scan. In addition to the partial C7 transfer, patients sustained nerve transfers to the posterior branch of the axillary nerve and to the motor branches of the musculocutaneous nerve for the biceps and brachialis muscles. RESULTS At a mean follow-up of 36 months (range, 29 to 42 months), mean shoulder abduction and external rotation ranges of motion were, respectively, 99 degrees (range, 60 to 120 degrees; p = 0.001) and 58 degrees (range, 0 to 80 degrees; p = 0.001). In nine patients, shoulder abduction strength was graded M4, according the British Medical Research Council grading scale, against 1.6 kg (range, 1 to 2 kg), and was graded M3 in one patient. External rotation strength was graded M4 in nine patients and M3 in one patient. Residual strength of the pectoralis major muscle was graded M4+ in every patient. CONCLUSIONS C7 partial transfer to the suprascapular nerve showed satisfactory results at long-term follow-up for active shoulder abduction and external rotation recovery in C5-C6 brachial plexus palsies. This technique replaced spinal accessory nerve transfer in the authors' practice. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Saltzman EB, Krishnan K, Winston MJ, Das De S, Lee SK, Wolfe SW. A Cadaveric Study on the Utility of the Levator Scapulae Motor Nerve as a Donor for Brachial Plexus Reconstruction. J Hand Surg Am 2021; 46:812.e1-812.e5. [PMID: 33487489 DOI: 10.1016/j.jhsa.2020.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 09/30/2020] [Accepted: 11/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the utility of the levator scapulae motor nerve (LSN) as a donor nerve for brachial plexus nerve transfer. We hypothesized that the LSN could be transferred to the suprascapular nerve (SSN) or long thoracic nerve (LTN) with a reliable tension-free coaptation and appropriate donor-to-recipient axon count ratio. METHODS Twelve brachial plexus dissections were performed on 6 adult cadavers, bilaterally. We identified the LSN, spinal accessory nerve (SAN), SSN, and LTN. Each nerve was prepared for transfer and nerve redundancies were calculated. Cross-sections of each nerve were examined histologically, and axons counted. We transferred the LSN to target first the SSN and then the LTN, in a tension-free coaptation. For reference, we transferred the distal SAN to target the SSN and LTN and compared transfer parameters. RESULTS Three cadavers demonstrated 2 LSN branches supplying the levator scapulae. The axon count ratio of donor-to-recipient nerve was 1:4.0 (LSN:SSN) and 1:2.1 (LSN:LTN) for a single LSN branch and 1:3.0 (LSN:SSN) and 1:1.6 (LSN:LTN) when 2 LSN branches were available. Comparatively, the axon count ratio of donor-to-recipient nerve was 1:2.5 and 1:1.3 for the SAN to the SSN and the LTN, respectively. The mean redundancy from the LSN to the SSN and the LTN was 1.7 cm (SD, 3.1 cm) and 2.9 cm (SD, 2.8 cm), and the redundancy from the SAN to the SSN and the LTN was 4.5 (SD, 0.7 cm) and 0.75 cm (SD, 1.0 cm). CONCLUSIONS These data support the use of the LSN as a potential donor for direct nerve transfer to the SSN and LTN, given its adequate redundancy and size match. CLINICAL RELEVANCE The LSN should be considered as an alternative nerve donor source for brachial plexus reconstruction, especially in 5-level injuries with scarce donor nerves. If used in lieu of the SAN during primary nerve reconstruction, trapezius tendon transfer for improved external rotation would be enabled.
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Affiliation(s)
- Eliana B Saltzman
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Karthik Krishnan
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY
| | - Mark J Winston
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Soumen Das De
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery
| | - Steve K Lee
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY
| | - Scott W Wolfe
- Center for Brachial Plexus and Traumatic Nerve Injury, Hospital for Special Surgery; Weill Medical College of Cornell University, New York, NY.
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Pages L, Le Hanneur M, Cambon-Binder A, Belkheyar Z. C5/C6 brachial plexus palsy reconstruction using nerve surgery: long-term functional outcomes. Orthop Traumatol Surg Res 2020; 106:1095-1100. [PMID: 32763010 DOI: 10.1016/j.otsr.2020.03.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 03/07/2020] [Accepted: 03/23/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In traumatic proximal brachial plexus lesions (i.e., C5/C6), reconstruction of the musculocutaneous, axillary and suprascapular nerves yields satisfactory short- and medium-term functional outcomes. HYPOTHESIS Early functional outcomes after nerve surgery will be maintained in the long-term. METHODS A retrospective analysis was done using the medical records of 29 patients with C5/C6 palsy treated by nerve surgery. Active range of motion and strength at the elbow (i.e., flexion) and shoulder (i.e., flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted ) were evaluated clinically using a goniometre and the British Medical Research Council grading scale, respectively. RESULTS At a mean follow-up of 46±15 months (25;76), the mean active elbow flexion was 126°±18° (90;150) and the mean strength was 3.8±0.5 (2;4). At the shoulder, mean active flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted were 109°±39° (0;180), 99°±38° (0;180°), 12°±34° (-80;70) and 3°±21° (-40;50), while mean strength was 3.6±0.8 (0;4), 3.6±0.8 (0;4), 3.4±0.9 (0;4) and 2.5±1.2 (0;4), respectively. DISCUSSION In cases of C5/C6 palsy, early nerve surgery yields satisfactory functional outcomes that are maintained over time for elbow flexion and shoulder elevation. However, when the teres minor is not reinnervated, it is difficult to restore satisfactory shoulder external rotation. LEVEL OF EVIDENCE IV, Retrospective case study.
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Affiliation(s)
- Laure Pages
- Department of Orthopedics and Traumatology - Service of Hand Surgery; Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), 46, rue Henry-Huchard, 75018 Paris, France
| | - Malo Le Hanneur
- Department of Orthopedics and Traumatology - Service of Hand, Upper Limb and Peripheral Nerve Surgery; Georges-Pompidou European Hospital (HEGP), Assistance Publique-Hôpitaux de Paris (AP-HP), 20, rue Leblanc, 75015 Paris, France.
| | - Adeline Cambon-Binder
- Department of Orthopedics and Traumatology - Service of Hand Surgery; Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Zoubir Belkheyar
- Department of Orthopedics - Service of Hand Surgery, Clinique du Mont-Louis, 8-10, rue de la Folie-Regnault, 75011 Paris, France
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de Mendonça Cardoso M, Gepp R, Lima FL, Gushiken A. Intercostal to musculocutaneous nerve transfer in patients with complete traumatic brachial plexus injuries: case series. Acta Neurochir (Wien) 2020; 162:1907-1912. [PMID: 32506331 DOI: 10.1007/s00701-020-04433-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 05/26/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND To recover biceps strength in patients with complete brachial plexus injuries, the intercostal nerve can be transferred to the musculocutaneous nerve. The surgical results are very controversial, and most of the studies with good outcomes and large samples were carried out in Asiatic countries. The objective of the study was to evaluate biceps strength after intercostal nerve transfer in patients undergoing this procedure in a Western country hospital. METHODS We retrospectively analyzed 39 patients from 2011 to 2016 with traumatic brachial plexus injuries receiving intercostal to musculocutaneous nerve transfer in a rehabilitation hospital. The biceps strength was graded using the British Medical Research Council (BMRC) scale. The variables reported and analyzed were age, the time between trauma and surgery, surgeon experience, body mass index, nerve receptor (biceps motor branch or musculocutaneous nerve), and the number of intercostal nerves transferred. Statistical tests, with a significance level of 5%, were used. RESULTS Biceps strength recovery was graded ≥M3 in 19 patients (48.8%) and M4 in 15 patients (38.5%). There was no statistical association between biceps strength and the variables. The most frequent complication was a pleural rupture. CONCLUSIONS Intercostal to musculocutaneous nerve transfer is a safe procedure. Still, biceps strength after surgery was ≥M3 in only 48.8% of the patients. Other donor nerve options should be considered, e.g., the phrenic or spinal accessory nerves.
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Engelmann S, Ruewe M, Geis S, Taeger CD, Kehrer M, Tamm ER, Bleys RLAW, Zeman F, Prantl L, Kehrer A. Rapid and Precise Semi-Automatic Axon Quantification in Human Peripheral Nerves. Sci Rep 2020; 10:1935. [PMID: 32029860 PMCID: PMC7005293 DOI: 10.1038/s41598-020-58917-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/20/2020] [Indexed: 11/09/2022] Open
Abstract
We developed a time-efficient semi-automated axon quantification method using freeware in human cranial nerve sections stained with paraphenylenediamine (PPD). It was used to analyze a total of 1238 facial and masseteric nerve biopsies. The technique was validated by comparing manual and semi-automated quantification of 129 (10.4%) randomly selected biopsies. The software-based method demonstrated a sensitivity of 94% and a specificity of 87%. Semi-automatic axon counting was significantly faster (p < 0.001) than manual counting. It took 1 hour and 47 minutes for all 129 biopsies (averaging 50 sec per biopsy, 0.04 seconds per axon). The counting process is automatic and does not need to be supervised. Manual counting took 21 hours and 6 minutes in total (average 9 minutes and 49 seconds per biopsy, 0.52 seconds per axon). Our method showed a linear correlation to the manual counts (R = 0.944 Spearman rho). Attempts have been made by several research groups to automate axonal load quantification. These methods often require specific hard- and software and are therefore only accessible to a few specialized laboratories. Our semi-automated axon quantification is precise, reliable and time-sparing using publicly available software and should be useful for an effective axon quantification in various human peripheral nerves.
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Affiliation(s)
- S Engelmann
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Ruewe
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - S Geis
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C D Taeger
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Kehrer
- Department of Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - E R Tamm
- Institute of Human Anatomy, University of Regensburg, Regensburg, Germany
| | - R L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - L Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - A Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.
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Dibble CF, Khalifeh JM, VanVoorhis A, Rich JT, Ray WZ. Novel Nerve Transfers for Motor and Sensory Restoration in High Cervical Spinal Cord Injury. World Neurosurg 2019; 128:611-615.e1. [DOI: 10.1016/j.wneu.2019.04.264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 04/29/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
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Le Hanneur M, Masmejean EH, Lafosse T. Direct transfer of C7 pectoral fascicles to the suprascapular nerve in C5/C6 brachial plexus palsies: an anatomical study. J Hand Surg Eur Vol 2019; 44:628-631. [PMID: 30871404 DOI: 10.1177/1753193419835436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We investigated a technique to reconstruct the suprascapular nerve in patients with C5/C6 brachial plexus palsies, using pectoral fascicles from the ipsilateral C7 root. Using a supraclavicular approach in eight cadavers, the suprascapular nerve was placed side by side with an anterior quadrant fascicle from the C7 root. Several criteria were assessed, including the fascicle length, the overlap between the two nerves and their respective diameters. The mean length of the C7 fascicles was 19.3 mm, with a mean overlap of 4.7 mm. The suprascapular nerve and the C7 fascicles had mean diameters of 2.2 mm and 2.1 mm, respectively. Pectoral fascicles from C7 seem to be an option for reconstruction of the suprascapular nerve in C5/C6 palsies. Clinical studies will be required to establish the potential limitations of this transfer, especially in cases with complex lesions of the suprascapular nerve.
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Affiliation(s)
- Malo Le Hanneur
- 1 Department of Orthopedics and Traumatology - Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Paris, France
| | - Emmanuel H Masmejean
- 1 Department of Orthopedics and Traumatology - Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Paris, France
| | - Thibault Lafosse
- 1 Department of Orthopedics and Traumatology - Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Paris, France.,2 Hand, Upper Limb, Brachial plexus, and Microsurgery Unit (PBMA), Clinique Générale d'Annecy, Annecy, France
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Kirk EA, Gilmore KJ, Stashuk DW, Doherty TJ, Rice CL. Human motor unit characteristics of the superior trapezius muscle with age-related comparisons. J Neurophysiol 2019; 122:823-832. [PMID: 31242057 DOI: 10.1152/jn.00138.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Current understanding of human motor unit (MU) control and aging is mostly derived from hand and limb muscles that have spinal motor neuron innervations. The aim here was to characterize and test whether a muscle with a shared innervation supply from brainstem and spinal MU populations would demonstrate similar age-related adaptations as those reported for other muscles. In humans, the superior trapezius (ST) muscle acts to elevate and stabilize the scapula and has primary efferent supply from the spinal accessory nerve (cranial nerve XI) located in the brainstem. We compared electrophysiological properties obtained from intramuscular and surface recordings between 10 young (22-33 yr) and 10 old (77-88 yr) men at a range of voluntary isometric contraction intensities (from 15 to 100% of maximal efforts). The old group was 41% weaker with 43% lower MU discharge frequencies compared with the young (47.2 ± 9.6 Hz young and 26.7 ± 5.8 Hz old, P < 0.05) during maximal efforts. There was no difference in MU number estimation between age groups (228 ± 105 young and 209 ± 89 old, P = 0.33). Furthermore, there were no differences in needle detected near fiber (NF) stability parameters of jitter or jiggle. The old group had lower amplitude and smaller area of the stimulated compound muscle action potential and smaller NF MU potential area with higher NF counts. Thus, despite age-related ST weakness and lower MU discharge rates, there was minimal evidence of MU loss or compensatory reinnervation.NEW & NOTEWORTHY The human superior trapezius (ST) has shared spinal and brainstem motor neuron innervation providing a unique model to explore the impact of aging on motor unit (MU) properties. Although the ST showed higher MU discharge rates compared with most spinally innervated muscles, voluntary strength and mean MU rates were lower in old compared with young at all contraction intensities. There was no age-related difference in MU number estimates with minimal electrophysiological evidence of collateral reinnervation.
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Affiliation(s)
- Eric A Kirk
- School of Kinesiology, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada
| | - Kevin J Gilmore
- School of Kinesiology, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada
| | - Daniel W Stashuk
- Department of Systems Design Engineering, University of Waterloo, Ontario, Canada
| | - Timothy J Doherty
- Department of Clinical Neurological Sciences, The University of Western Ontario, London, Ontario, Canada.,Department of Physical Medicine and Rehabilitation, The University of Western Ontario, London, Ontario, Canada
| | - Charles L Rice
- School of Kinesiology, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada.,Department of Anatomy and Cell Biology, The University of Western Ontario, London, Ontario, Canada
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Bulstra LF, Rbia N, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Spinal accessory nerve to triceps muscle transfer using long autologous nerve grafts for recovery of elbow extension in traumatic brachial plexus injuries. J Neurosurg 2018; 129:1041-1047. [DOI: 10.3171/2017.6.jns17290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEReconstructive options for brachial plexus lesions continue to expand and improve. The purpose of this study was to evaluate the prevalence and quality of restored elbow extension in patients with brachial plexus injuries who underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle with an intervening autologous nerve graft and to identify patient and injury factors that influence functional triceps outcome.METHODSA total of 42 patients were included in this retrospective review. All patients underwent transfer of the spinal accessory nerve to the motor branch of the radial nerve to the long head of the triceps muscle as part of their reconstruction plan after brachial plexus injury. The primary outcome was elbow extension strength according to the modified Medical Research Council muscle grading scale, and signs of triceps muscle recovery were recorded using electromyography.RESULTSWhen evaluating the entire study population (follow-up range 12–45 months, mean 24.3 months), 52.4% of patients achieved meaningful recovery. More specifically, 45.2% reached Grade 0 or 1 recovery, 19.1% obtained Grade 2, and 35.7% improved to Grade 3 or better. The presence of a vascular injury impaired functional outcome. In the subgroup with a minimum follow-up of 20 months (n = 26), meaningful recovery was obtained by 69.5%. In this subgroup, 7.7% had no recovery (Grade 0), 19.2% had recovery to Grade 1, and 23.1% had recovery to Grade 2. Grade 3 or better was reached by 50% of patients, of whom 34.5% obtained Grade 4 elbow extension.CONCLUSIONSTransfer of the spinal accessory nerve to the radial nerve branch to the long head of the triceps muscle with an interposition nerve graft is an adequate option for restoration of elbow extension, despite the relatively long time required for reinnervation. The presence of vascular injury impairs functional recovery of the triceps muscle, and the use of shorter nerve grafts is recommended when and if possible.
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Affiliation(s)
- Liselotte F. Bulstra
- Departments of 1Orthopedic Surgery, Division of Hand Surgery, and
- 3Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nadia Rbia
- Departments of 1Orthopedic Surgery, Division of Hand Surgery, and
- 3Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Allen T. Bishop
- Departments of 1Orthopedic Surgery, Division of Hand Surgery, and
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Johal J, Iwanaga J, Tubbs K, Loukas M, Oskouian RJ, Tubbs RS. The Accessory Nerve: A Comprehensive Review of its Anatomy, Development, Variations, Landmarks and Clinical Considerations. Anat Rec (Hoboken) 2018; 302:620-629. [DOI: 10.1002/ar.23823] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/11/2017] [Accepted: 05/14/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Jaspreet Johal
- Department of Anatomical SciencesSt. George's UniversitySt. George's Grenada
- Seattle Science FoundationSeattle Washington
| | - Joe Iwanaga
- Seattle Science FoundationSeattle Washington
| | - Kevin Tubbs
- Seattle Science FoundationSeattle Washington
| | - Marios Loukas
- Department of Anatomical SciencesSt. George's UniversitySt. George's Grenada
| | | | - R. Shane Tubbs
- Department of Anatomical SciencesSt. George's UniversitySt. George's Grenada
- Seattle Science FoundationSeattle Washington
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14
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Tubbs RS, Maldonado AA, Stoves Y, Fries FN, Li R, Loukas M, Oskouian RJ, Spinner RJ. A novel method of lengthening the accessory nerve for direct coaptation during nerve repair and nerve transfer procedures. J Neurosurg 2017; 128:272-276. [PMID: 28298044 DOI: 10.3171/2016.10.jns161106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The accessory nerve is frequently repaired or used for nerve transfer. The length of accessory nerve available is often insufficient or marginal (under tension) for allowing direct coaptation during nerve repair or nerve transfer (neurotization), necessitating an interpositional graft. An attractive maneuver would facilitate lengthening of the accessory nerve for direct coaptation. The aim of the present study was to identify an anatomical method for such lengthening. METHODS In 20 adult cadavers, the C-2 or C-3 connections to the accessory nerve were identified medial to the sternocleidomastoid (SCM) muscle and the anatomy of the accessory nerve/cervical nerve fibers within the SCM was documented. The cervical nerve connections were cut. Lengths of the accessory nerve were measured. Samples of the cut C-2 and C-3 nerves were examined using immunohistochemistry. RESULTS The anatomy and adjacent neural connections within the SCM are complicated. However, after the accessory nerve was "detethered" from within the SCM and following transection, the additional length of the accessory nerve increased from a mean of 6 cm to a mean of 10.5 cm (increase of 4.5 cm) after cutting the C-2 connections, and from a mean of 6 cm to a mean length of 9 cm (increase of 3.5 cm) after cutting the C-3 connections. The additional length of accessory nerve even allowed direct repair of an infraclavicular target (i.e., the proximal musculocutaneous nerve). The cervical nerve connections were shown not to contain motor fibers. CONCLUSIONS An additional length of the accessory nerve made available in the posterior cervical triangle can facilitate direct repair or neurotization procedures, thus eliminating the need for an interpositional nerve graft, decreasing the time/distance for regeneration and potentially improving clinical outcomes.
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Affiliation(s)
- R Shane Tubbs
- 1Seattle Science Foundation.,2Department of Anatomical Sciences, St. George's University,Grenada
| | | | - Yolanda Stoves
- 4Department of Pathology, Children's of Alabama, Birmingham, Alabama; and
| | - Fabian N Fries
- 5Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg,Germany
| | - Rong Li
- 4Department of Pathology, Children's of Alabama, Birmingham, Alabama; and
| | - Marios Loukas
- 2Department of Anatomical Sciences, St. George's University,Grenada
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15
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Bertelli JA, Ghizoni MF. Results of spinal accessory to suprascapular nerve transfer in 110 patients with complete palsy of the brachial plexus. J Neurosurg Spine 2016; 24:990-5. [DOI: 10.3171/2015.8.spine15434] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Transfer of the spinal accessory nerve to the suprascapular nerve is a common procedure, performed to reestablish shoulder motion in patients with total brachial plexus palsy. However, the results of this procedure remain largely unknown.
METHODS
Over an 11-year period (2002–2012), 257 patients with total brachial plexus palsy were operated upon in the authors' department by a single surgeon and had the spinal accessory nerve transferred to the suprascapular nerve. Among these, 110 had adequate follow-up and were included in this study. Their average age was 26 years (SD 8.4 years), and the mean interval between their injury and surgery was 5.2 months (SD 2.4 months). Prior to 2005, the suprascapular and spinal accessory nerves were dissected through a classic supraclavicular L-shape incision (n = 29). Afterward (n = 81), the spinal accessory and suprascapular nerves were dissected via an oblique incision, extending from the point at which the plexus crossed the clavicle to the anterior border of the trapezius muscle. In 17 of these patients, because of clavicle fractures or dislocation, scapular fractures or retroclavicular scarring, the incision was extended by detaching the trapezius from the clavicle to expose the suprascapular nerve at the suprascapular fossa. In all patients, the brachial plexus was explored and elbow flexion reconstructed by root grafting (n = 95), root grafting and phrenic nerve transfer (n = 6), phrenic nerve transfer (n = 1), or third, fourth, and fifth intercostal nerve transfer. Postoperatively, patients were followed for an average of 40 months (SD 13.7 months).
RESULTS
Failed recovery, meaning less than 30° abduction, was observed in 10 (9%) of the 110 patients. The failure rate was 25% between 2002 and 2004, but dropped to 5% after the staged/extended approach was introduced. The mean overall range of abduction recovery was 58.5° (SD 26°). Comparing before and after distal suprascapular nerve exploration (2005–2012), the range of abduction recovery was 45° (SD 25.1°) versus 62° (SD 25.3°), respectively (p = 0.002). In patients who recovered at least 30° of abduction, recovery of elbow flexion to at least an M3 level of strength increased the range of abduction by an average of 13° (p = 0.01). Before the extended approach, 2 (7%) of 29 patients recovered active external rotation of 20° and 120°. With the staged/extended approach, 32 (40%) of 81 recovered some degree of active external rotation. In these patients, the average range of motion measured from the thorax was 87° (SD 40.6°).
CONCLUSIONS
In total palsies of the brachial plexus, using the spinal accessory nerve for transfer to the suprascapular nerve is reliable and provides some recovery of abduction for a large majority of patients. In a few patients, a more extensive approach to access the suprascapular nerve, including, if necessary, dissection in the suprascapular fossa, may enhance outcomes.
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Affiliation(s)
- Jayme Augusto Bertelli
- 1Department of Neurosurgery, Southern University of Santa Catarina (Unisul), Tubarão; and
- 2Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Marcos Flávio Ghizoni
- 1Department of Neurosurgery, Southern University of Santa Catarina (Unisul), Tubarão; and
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16
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Baltzer HL, Wagner ER, Kircher MF, Spinner RJ, Bishop AT, Shin AY. Evaluation of infraspinatus reinnervation and function following spinal accessory nerve to suprascapular nerve transfer in adult traumatic brachial plexus injuries. Microsurgery 2016; 37:365-370. [PMID: 27206345 DOI: 10.1002/micr.30070] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/22/2016] [Accepted: 05/04/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE Our objective was to determine the prevalence and quality of restored external rotation (ER) in adult brachial plexus injury (BPI) patients who underwent spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, and to identify patient and injury factors that may influence results. METHODS Fifty-one adult traumatic BPI patients who underwent SAN to SSN transfer between 2000 and 2013, all treated less than 1 year after injury with >1 year follow-up. The primary outcome measured was shoulder ER. The outcomes we utilized included "clinically useful ER" (motion ≥ -35° with ≥MRC 2 strength), modified British Medical Research Council (MRC) grading, and electromyographic (EMG) reinnervation. RESULTS EMG evidence of re-innervation was found in 85% of patients. Surgery resulted in improved ER in 41% (21/51) of shoulders at an average of 28 months follow-up. Of these, only 31% (17/51) had clinically useful ER. The average ER active range of motion was 12° from full internal rotation (Range: -60° to 90°) and MRC grade 2.2 (2-4). The only predictor of ER improvement was an isolated upper trunk (C5-C6) injury. Improved ER was clinically evident in 76%, 37% and 26% of upper trunk (UT), C5-C6-C7 and panplexus injuries, respectively (P < 0.03). CONCLUSIONS Although 85% had EMG signs of recovery, the SAN to SSN transfer failed to provide useful recovery of ER through reinnervation of the infraspinatus muscle in injuries involving more levels than a C5-C6 root/upper trunk pattern. In patients with greater than C5-6 level injuries alternatives to SAN to SSN transfer should be considered to restore shoulder ER. © 2016 Wiley Periodicals, Inc. Microsurgery 37:365-370, 2017.
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Affiliation(s)
- Heather L Baltzer
- Department of Orthopedic Surgery and the Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN
| | - Eric R Wagner
- Department of Orthopedic Surgery and the Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN
| | - Michelle F Kircher
- Department of Orthopedic Surgery and the Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN
| | - Robert J Spinner
- Department of Orthopedic Surgery and the Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN
| | - Allen T Bishop
- Department of Orthopedic Surgery and the Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN
| | - Alexander Y Shin
- Department of Orthopedic Surgery and the Department of Neurosurgery, Mayo Clinic, 200 First St SW, Rochester, MN
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17
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Shapira Y, Midha R. Editorial: Modified extended approach improves recovery following spinal accessory to suprascapular nerve transfer. J Neurosurg Spine 2016; 24:986-9. [PMID: 26871648 DOI: 10.3171/2015.9.spine15960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yuval Shapira
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel; and
| | - Rajiv Midha
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
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18
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Abstract
Abstract
Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.
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Affiliation(s)
- Wilson Z. Ray
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jason Chang
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ammar Hawasli
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas J. Wilson
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lynda Yang
- Department of Neurological Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
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19
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Optimal Axon Counts for Brachial Plexus Nerve Transfers to Restore Elbow Flexion. Plast Reconstr Surg 2015; 135:135e-141e. [DOI: 10.1097/prs.0000000000000795] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Peripheral nerve injuries: advancing the field through research, collaboration, and education. J Hand Surg Am 2014; 39:2052-8. [PMID: 25124088 DOI: 10.1016/j.jhsa.2014.06.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 06/24/2014] [Accepted: 06/24/2014] [Indexed: 02/02/2023]
Abstract
The Andrew J. Weiland Medal is presented each year by the American Society for Surgery of the Hand and the American Foundation for Surgery of the Hand for a body of work related to hand surgery research. This essay, awarded the Weiland Medal in 2013, focuses on advancing the field of peripheral nerve injuries through research, collaboration, and education.
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Sahakyants T, Lee JY, Friedrich PF, Bishop AT, Shin AY. Return of motor function after repair of a 3-cm gap in a rabbit peroneal nerve: a comparison of autograft, collagen conduit, and conduit filled with collagen-GAG matrix. J Bone Joint Surg Am 2013; 95:1952-8. [PMID: 24196465 DOI: 10.2106/jbjs.m.00215] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the motor nerve recovery in a rabbit model after repair of a 3-cm gap in the peroneal nerve with a conduit filled with a collagen-GAG (glycosaminoglycan) matrix and compare the results with those after reconstruction with an autograft or an empty collagen conduit. METHODS Forty-two male New Zealand rabbits were divided into three experimental groups. In each group, a unilateral 3-cm peroneal nerve defect was repaired with a nerve autograft, an empty collagen conduit, or a conduit filled with a collagen-GAG matrix. At six months, nerve regeneration was evaluated on the basis of the compound muscle action potentials, maximum isometric tetanic force, and wet muscle weight of the tibialis anterior muscle as well as nerve histomorphometry. RESULTS The autograft group had significantly better motor recovery than the conduit groups. The empty collagen conduits and conduits filled with the collagen-GAG matrix led to results that were similar to each other. CONCLUSIONS On the basis of this rabbit model, autologous nerve grafting remains the gold standard in the reconstruction of 3-cm segmental motor nerve defects. CLINICAL RELEVANCE Segmental motor nerve defects should be reconstructed with autograft nerves. The use of a collagen conduit filled with a collagen-GAG matrix for motor nerve reconstruction should be limited until additional animal studies are performed.
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Affiliation(s)
- Tatevik Sahakyants
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905. E-mail address for A.Y. Shin:
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22
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Ren GH, Li RG, Xiang DY, Yu B. Reconstruction of shoulder abduction by multiple nerve fascicle transfer through posterior approach. Injury 2013; 44:492-7. [PMID: 23219242 DOI: 10.1016/j.injury.2012.10.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 10/13/2012] [Accepted: 10/24/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the feasibility and clinical efficacy of multiple nerve fascicle transfer through posterior approach for reconstruction of shoulder abduction in patients with C5 or upper brachial plexus injury. METHODS 11 patients (aged between 17 and 56 years) with dysfunction of shoulder abduction post C5 or upper brachial plexus injury were recruited in this study. Among them, four out of 11 patients also had dysfunction of elbow flexion simultaneously. The duration from injury to the surgery ranged from 4 to 12 months, with an average of 6.7 months. The affected shoulder joints showed abduction, extension and elevation dysfunction, but the muscle strength of shoulder shrugging and elbow extension was graded to M4 or higher. Accessory nerve was transferred to the suprascapular nerve and triceps muscle was branched to the axillary nerve through posterior approach. Ulnar fascicle was transferred to the motor branches of biceps for the 4 patients involved with elbow flexion dysfunction. RESULTS Ten out of 11 cases were followed-up for 15-36 months. Neo-potential of deltoid and supraspinatus/infraspinatus was documented at 4-5 months post surgery. Shoulder abduction (and elbow flexion) was reanimated at 4-8 months post surgery. Significant improvement was observed at 15-36 months post surgery, shoulder abduction regained to 40-160° (mean: 92.5°), muscle strength of supraspinatus/infraspinatus and deltoid were graded to M3-M5 (mean: 4.0 and 4.1); 3 cases muscle strength of elbow flexion was graded from M4 to M5- (mean: 4.4) with 1 case loss. Shoulder shrugging of trapezius was graded to M5 in 5 cases, M5- in 2 cases, M4 in 2 cases and M3 in 1 case (mean: 4.5). All cases showed normal elbow extension and muscle strength of triceps (M5). CONCLUSION It is feasible to carry out multiple nerve fascicle transfers for early reconstruction of shoulder abduction by posterior approach. Patients who received this procedure achieved good functional recovery and their donor site morbidity/injury was minimal.
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Affiliation(s)
- Gao-hong Ren
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, PR China.
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23
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Giusti G, Kremer T, Willems WF, Friedrich PF, Bishop AT, Shin AY. Description and validation of isometric tetanic muscle force test in rabbits. Microsurgery 2011; 32:35-42. [DOI: 10.1002/micr.20941] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 06/20/2011] [Indexed: 01/18/2023]
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24
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Lu J, Xu J, Xu W, Xu L, Fang Y, Chen L, Gu Y. Combined nerve transfers for repair of the upper brachial plexus injuries through a posterior approach. Microsurgery 2011; 32:111-7. [PMID: 22002897 DOI: 10.1002/micr.20962] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 08/24/2011] [Indexed: 11/07/2022]
Abstract
The upper brachial plexus injury leads to paralysis of muscles innervated by C5 and C6 nerve roots. In this report, we present our experience on the use of the combined nerve transfers for reconstruction of the upper brachial plexus injury. Nine male patients with the upper brachial plexus injury were treated with combined nerve transfers. The time interval between injury and surgery ranged from 3 to 11 months (average, 7 months). The combined nerve transfers include fascicles of the ulnar nerve and/or the median nerve transfer to the biceps and/or the brachialis motor branch, and the spinal accessory nerve (SAN) to the suprascapular nerve (SSN) and triceps branches to the axillary nerve through a posterior approach. At an average of 33 months of follow-up, all patients recovered the full range of the elbow flexion. Six out of nine patients were able to perform the normal range of shoulder abduction with the strength degraded to M3 or M4. These results showed that the technique of the combined nerve transfers, specifically the SAN to the SSN and triceps branches to the axillary nerve through a posterior approach, may be a valuable alternative in the repair of the upper brachial plexus injury. Further evaluations of this technique are necessary.
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Affiliation(s)
- Jiuzhou Lu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
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25
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Wehrli L, Bonnard C, Anastakis DJ. Current Status of Brachial Plexus Reconstruction: Restoration of Hand Function. Clin Plast Surg 2011; 38:661-81. [DOI: 10.1016/j.cps.2011.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yang ML, Li JJ, Zhang SC, Du LJ, Gao F, Li J, Wang YM, Gong HM, Cheng L. Functional restoration of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization utilizing the functional spinal accessory nerve. J Neurosurg Spine 2011; 15:190-4. [PMID: 21529201 DOI: 10.3171/2011.3.spine10911] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report a case of functional improvement of the paralyzed diaphragm in high cervical quadriplegia via phrenic nerve neurotization using a functional spinal accessory nerve. Complete spinal cord injury at the C-2 level was diagnosed in a 44-year-old man. Left diaphragm activity was decreased, and the right diaphragm was completely paralyzed. When the level of metabolism or activity (for example, fever, sitting, or speech) slightly increased, dyspnea occurred. The patient underwent neurotization of the right phrenic nerve with the trapezius branch of the right spinal accessory nerve at 11 months postinjury. Four weeks after surgery, training of the synchronous activities of the trapezius muscle and inspiration was conducted. Six months after surgery, motion was observed in the previously paralyzed right diaphragm. The lung function evaluation indicated improvements in vital capacity and tidal volume. This patient was able to sit in a wheelchair and conduct outdoor activities without assisted ventilation 12 months after surgery.
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Affiliation(s)
- Ming-liang Yang
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Jian-jun Li
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | | | - Liang-jie Du
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Feng Gao
- 4Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China
| | - Jun Li
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Yu-ming Wang
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Hui-ming Gong
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
| | - Liang Cheng
- 1Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center
- 2Faculty of Rehabilitation Medicine, Capital Medical University, Beijing
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Tubbs RS, Mortazavi MM, Shoja MM, Loukas M, Cohen-Gadol AA. Contralateral spinal accessory nerve for ipsilateral neurotization of branches of the brachial plexus: a cadaveric feasibility study. J Neurosurg 2011; 114:1538-40. [PMID: 21375378 DOI: 10.3171/2011.2.jns1122] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Additional nerve transfer options are important to the peripheral nerve surgeon to maximize patient outcomes following nerve injuries. Potential regional donors may also be injured or involved in the primary disease. Therefore, potential contralateral donor nerves would be desirable. To the authors' knowledge, use of the contralateral spinal accessory nerve (SAN) has not been explored for ipsilateral neurotization procedures. In the current study, therefore, the authors aimed to evaluate the SAN as a potential donor nerve for contralateral nerve injuries by using a novel technique.
Methods
In 10 cadavers, the SAN was harvested using a posterior approach, and tunneled subcutaneously to the contralateral side for neurotization to various branches of the brachial plexus. Measurements were made of the SAN available for transfer and of its diameter.
Results
The authors found an SAN length of approximately 20 cm (from transition of upper and middle fibers of the trapezius muscle to approximately 2–4 cm superior to the insertion of the trapezius muscle onto the spinous process of T-12) available for nerve transposition. The average diameter was 2.5 mm.
Conclusions
Based on these findings, the contralateral SAN may be considered for ipsilateral neurotization to the suprascapular and axillary nerves.
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Affiliation(s)
- R. Shane Tubbs
- 1Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - Martin M. Mortazavi
- 1Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - Mohammadali M. Shoja
- 2Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, Indiana; and
| | - Marios Loukas
- 3Department of Anatomical Sciences, St. George's University, Grenada, West Indies
| | - Aaron A. Cohen-Gadol
- 2Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, Indiana; and
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Outcomes of direct muscle neurotisation in adult facial paralysis. J Plast Reconstr Aesthet Surg 2011; 64:174-84. [PMID: 20643594 DOI: 10.1016/j.bjps.2010.04.045] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 04/21/2010] [Accepted: 04/23/2010] [Indexed: 11/23/2022]
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The trapezius-splitting approach: modifications for treating disorders and traumas occurring in the lateral supraspinatus fossa. THE JOURNAL OF TRAUMA 2010; 69:715-9. [PMID: 20838143 DOI: 10.1097/ta.0b013e3181edbc3e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Disorders or traumas requiring surgery other than suprascapular entrapment neuropathy that occur in the lateral supraspinatus fossa are decidedly uncommon. Because a wider operative field is necessary for treating these disorders, we have applied a trapezius-splitting approach with some modifications. METHODS The procedure comprises a saber cut incision along with trapezius-splitting of 5 cm to 6 cm proximally from the position coinciding with the posterior margin of the acromioclavicular joint. At the lateral aspect of this division, a Gelpi retractor is set on the clavicle and the scapular spine to widen the narrow interspace between them. The underlying adipose tissue and supraspinatus muscle are forced aside en bloc posteriorly. Four patients were surgically treated using this approach and were postoperatively followed up for 22.2 months ± 7.8 months. RESULTS A sufficient operative field for the major maneuver was secured in all four patients. None developed postoperative paralysis or atrophy of the trapezius, supraspinatus, or infraspinatus muscles. The three patients treated for nonunion or delayed union of coracoid fracture exhibited successful union, and the patient treated for osteochondroma of the clavicle had no recurrence. CONCLUSIONS The main advantages of this procedure are minimal trauma to the musculature, a clearly visible field of the most lateral fossa, and the ability to approach the anterior or posterior shoulder region through the extended skin incision and deltoid-splitting approach if required. Results indicate that the procedure would be advantageous in the surgical treatment of disorders and traumas occurring in the lateral supraspinatus fossa.
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