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Lavorato A, Aruta G, De Marco R, Zeppa P, Titolo P, Colonna MR, Galeano M, Costa AL, Vincitorio F, Garbossa D, Battiston B. Traumatic peripheral nerve injuries: a classification proposal. J Orthop Traumatol 2023; 24:20. [PMID: 37162617 PMCID: PMC10172513 DOI: 10.1186/s10195-023-00695-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 04/02/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Peripheral nerve injuries (PNIs) include several conditions in which one or more peripheral nerves are damaged. Trauma is one of the most common causes of PNIs and young people are particularly affected. They have a significant impact on patients' quality of life and on the healthcare system, while timing and type of surgical treatment are of the utmost importance to guarantee the most favorable functional recovery. To date, several different classifications of PNIs have been proposed, most of them focusing on just one or few aspects of these complex conditions, such as type of injury, anatomic situation, or prognostic factors. Current classifications do not enable us to have a complete view of this pathology, which includes diagnosis, treatment choice, and possible outcomes. This fragmentation sometimes leads to an ambiguous definition of PNIs and the impossibility of exchanging crucial information between different physicians and healthcare structures, which can create confusion in the choice of therapeutic strategies and timing of surgery. MATERIALS The authors retrospectively analyzed a group of 24 patients treated in their center and applied a new classification for PNI injuries. They chose (a) five injury-related factors, namely nerve involved, lesion site, nerve type (whether motor, sensory or mixed), surrounding tissues (whether soft tissues were involved or not), and lesion type-whether partial/in continuity or complete. An alphanumeric code was applied to each of these classes, and (b) four prognostic codes, related to age, timing, techniques, and comorbidities. RESULTS An alphanumeric code was produced, similar to that used in the AO classification of fractures. CONCLUSIONS The authors propose this novel classification for PNIs, with the main advantage to allow physicians to easily understand the characteristics of nerve lesions, severity, possibility of spontaneous recovery, onset of early complications, need for surgical treatment, and the best surgical approach. LEVEL OF EVIDENCE according to the Oxford 2011 level of evidence, level 2.
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Affiliation(s)
- Andrea Lavorato
- Neurosurgery Unit, Igea Hospital, via Marcona 69, 20129, Milan, Italy
| | - Gelsomina Aruta
- Department of Neurosciences "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Raffaele De Marco
- Department of Neurosciences "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Pietro Zeppa
- Department of Neurosciences "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Paolo Titolo
- Traumatology-Reconstructive Microsurgery, Department of Orthopedics and Traumatology, CTO Hospital, Turin, Italy
| | - Michele Rosario Colonna
- Department Human Pathology, University of Messina, Viale Della Libertà 395, 98121, Messina, Italy.
| | - Mariarosaria Galeano
- Department of Biological Imaging and Morphology, University of Messina, Messina, Italy
| | - Alfio Luca Costa
- Clinic of Plastic Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Francesca Vincitorio
- Department of Neurosciences "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neurosciences "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Turin, Italy
| | - Bruno Battiston
- Traumatology-Reconstructive Microsurgery, Department of Orthopedics and Traumatology, CTO Hospital, Turin, Italy
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Velichanskaya AG, Abrosimov DA, Bugrova ML, Kazakov AV, Pogadaeva EV, Radaev AM, Blagova NV, Vasyagina TI, Ermolin IL. Reconstruction of the Rat Sciatic Nerve by Using Biodegradable and Non-Biodegradable Conduits. Sovrem Tekhnologii Med 2021; 12:48-54. [PMID: 34796004 PMCID: PMC8596261 DOI: 10.17691/stm2020.12.5.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Indexed: 01/15/2023] Open
Abstract
The aim of the study was to compare two types of conduits made of either non-resorbable Reperen or resorbable Tissucol for their effects on the regeneration of the rat sciatic nerve under conditions of stump diastasis.
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Affiliation(s)
- A G Velichanskaya
- Associate Professor, Department of Histology, Cytology, and Embryology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - D A Abrosimov
- Senior Lecturer, Department of Histology, Cytology, and Embryology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - M L Bugrova
- Associate Professor, Head of the Department of Electron Microscopy, Central Research Laboratory; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A V Kazakov
- Researcher, Research Laboratory, Clinic of Cardiology, Angiology, and Intensive Care; Saarland University, Saarbrücken Campus, Saarbrücken, 66123, Germany
| | - E V Pogadaeva
- Senior Laboratory Assistant, Department of Histology, Cytology, and Embryology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - A M Radaev
- Associate Professor, Department of Histology, Cytology, and Embryology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - N V Blagova
- Senior Lecturer, Department of Histology Cytology, and Embryology; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - T I Vasyagina
- Senior Researcher, Department of Electron Microscopy, Central Research Laboratory; Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
| | - I L Ermolin
- Professor, Head of the Department of Histology, Cytology, and Embryology Privolzhsky Research Medical University, 10/1 Minin and Pozharsky Square, Nizhny Novgorod, 603005, Russia
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Armas-Salazar A, García-Jerónimo AI, Villegas-López FA, Navarro-Olvera JL, Carrillo-Ruiz JD. Clinical outcomes report in different brachial plexus injury surgeries: a systematic review. Neurosurg Rev 2021; 45:411-419. [PMID: 34142268 DOI: 10.1007/s10143-021-01574-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/30/2021] [Accepted: 05/26/2021] [Indexed: 01/20/2023]
Abstract
Brachial plexus injury is a lesion that results in loss of function of the arm, and there are multiple ways of surgically approaching its treatment. Controlled trials that compare all surgical repair strategies and their clinical outcomes have not been performed. A systematic review was conducted to identify all articles that reported clinical outcomes in different surgeries (nerve transfer, nerve graft, neurolysis, end-to-end, multiple interventions, and others). Advanced search in PubMed was performed using the Mesh terms "brachial plexus injury" as the main topic and "surgery" as a subtopic, obtaining a total of 2153 articles. The clinical data for eligibility extraction was focused on collecting motor, sensory, pain, and functional recovery. A statistical analysis was performed to find the superior surgical techniques in terms of motor recovery, through the assessment of heterogeneity between groups, and of relationships between surgery and motor recovery. The frequency and the manner in which clinical outcomes are recording were described. The differences that correspond to the demographics and procedural factors were not statistically significant among groups (p > 0.05). Neurolysis showed the highest proportion of motor recovery (85.18%), with significant results between preoperative and post-operative motor assessment (p = 0.028). The proportion of motor recovery in each group according to the surgical approach differed significantly (X2 = 82.495, p = 0.0001). The motor outcome was the most reported clinical outcome (97.56%), whereas the other clinical outcomes were reported in less than 15% of the included articles. Unexpectedly, neurolysis, a technique displaced by new surgical alternatives such as nerve transfer/graft, demonstrated the highest proportion of motor recovery. Clinical outcomes such as pain, sensory, and functional recovery were infrequently reported. These results introduce the need to re-evaluate neurolysis through comparative clinical trials, as well as to standardize the way in which clinical outcomes are reported.
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Affiliation(s)
- A Armas-Salazar
- Mexican Faculty of Medicine, La Salle University, Mexico City, Mexico
- Functional & Stereotactic Neurosurgery & Radiosurgery Service, General Hospital of Mexico, Doctor Balmis 148 Doctores, México City, 06720, México
| | - A I García-Jerónimo
- Functional & Stereotactic Neurosurgery & Radiosurgery Service, General Hospital of Mexico, Doctor Balmis 148 Doctores, México City, 06720, México
| | - F A Villegas-López
- Functional & Stereotactic Neurosurgery & Radiosurgery Service, General Hospital of Mexico, Doctor Balmis 148 Doctores, México City, 06720, México
| | - J L Navarro-Olvera
- Functional & Stereotactic Neurosurgery & Radiosurgery Service, General Hospital of Mexico, Doctor Balmis 148 Doctores, México City, 06720, México
| | - J D Carrillo-Ruiz
- Functional & Stereotactic Neurosurgery & Radiosurgery Service, General Hospital of Mexico, Doctor Balmis 148 Doctores, México City, 06720, México.
- Research Direction of General Hospital of Mexico, Mexico City, Mexico.
- Faculty of Health Sciences Direction, of Anahuac University Mexico, Mexico City, Mexico.
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Martin E, Senders JT, DiRisio AC, Smith TR, Broekman MLD. Timing of surgery in traumatic brachial plexus injury: a systematic review. J Neurosurg 2018:1-13. [PMID: 29999446 DOI: 10.3171/2018.1.jns172068] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 01/10/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVEIdeal timeframes for operating on traumatic stretch and blunt brachial plexus injuries remain a topic of debate. Whereas on the one hand spontaneous recovery might occur, on the other hand, long delays are believed to result in poorer functional outcomes. The goal of this review is to assess the optimal timeframe for surgical intervention for traumatic brachial plexus injuries.METHODSA systematic search was performed in January 2017 in PubMed and Embase databases according to the PRISMA guidelines. Search terms related to "brachial plexus injury" and "timing" were used. Obstetric plexus palsies were excluded. Qualitative synthesis was performed on all studies. Timing of operation and motor outcome were collected from individual patient data. Patients were categorized into 5 delay groups (0-3, 3-6, 6-9, 9-12, and > 12 months). Median delays were calculated for Medical Research Council (MRC) muscle grade ≥ 3 and ≥ 4 recoveries.RESULTSForty-three studies were included after full-text screening. Most articles showed significantly better motor outcome with delays to surgery less than 6 months, with some studies specifying even shorter delays. Pain and quality of life scores were also significantly better with shorter delays. Nerve reconstructions performed after long time intervals, even more than 12 months, can still be useful. All papers reporting individual-level patient data described a combined total of 569 patients; 65.5% of all patients underwent operations within 6 months and 27.4% within 3 months. The highest percentage of ≥ MRC grade 3 (89.7%) was observed in the group operated on within 3 months. These percentages decreased with longer delays, with only 35.7% ≥ MRC grade 3 with delays > 12 months. A median delay of 4 months (IQR 3-6 months) was observed for a recovery of ≥ MRC grade 3, compared with a median delay of 7 months (IQR 5-11 months) for ≤ MRC grade 3 recovery.CONCLUSIONSThe results of this systematic review show that in stretch and blunt injury of the brachial plexus, the optimal time to surgery is shorter than 6 months. In general, a 3-month delay appears to be appropriate because while recovery is better in those operated on earlier, this must be considered given the potential for spontaneous recovery.
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Affiliation(s)
- Enrico Martin
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and.,2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joeky T Senders
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and.,2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aislyn C DiRisio
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- 2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marike L D Broekman
- 1Department of Neurosurgery, University Medical Center Utrecht, The Netherlands; and.,2Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Rinkinen JR, Giladi AM, Iorio ML. Outcomes Following Peripheral Nerve Transfers for Treatment of Non-Obstetric Brachial Plexus Upper-Extremity Neuropathy. JBJS Rev 2018; 6:e1. [PMID: 29613866 DOI: 10.2106/jbjs.rvw.17.00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jacob R Rinkinen
- Division of Plastic and Reconstructive Surgery (J.R.R. and M.L.I.) and Department of Orthopaedics (A.M.G. and M.L.I.), Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Magnetic Resonance Neurographic and Clinical Long-Term Results After Oberlin's Transfer for Adult Brachial Plexus Injuries. Ann Plast Surg 2017; 78:67-72. [PMID: 27801698 DOI: 10.1097/sap.0000000000000924] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The primary goal of the surgical treatment of upper brachial plexus injuries is to restore active elbow flexion. Accordingly, Oberlin's transfer has been frequently performed since 1994 and has influenced the development of other nerve transfers. However, the window of opportunity for nerve transfers remains a subject of controversy. The objective of this study was to assess magnetic resonance (MR) neurographic, clinical and electrophysiological long-term results after Oberlin's transfer. For this purpose, we performed a retrospective follow-up study. Six patients with upper brachial plexus or musculocutaneous nerve injuries were assessed; 2 were iatrogenic nerve injuries following shoulder arthroscopy or neurofibroma resection. Direct and indirect signs of neuropathy were objectified with MR neurography. Moreover, clinical and electrodiagnostic follow-up was performed and all patients completed the Disabilities of Arm, Shoulder and Hand score. Mean follow-up was 48 ± 21.9 (range, 20-73) months. Mean age was 40 ± 11.3 years and mean delay to surgery was 9 ± 3.2 months. All patients were satisfied with the functional results and the median Disabilities of Arm, Shoulder and Hand score was 21 (range, 1-57). Biceps strength was improved in 5 patients from Medical Research Council grade M0 to M4-5 and in one patient to M2-3. The donor nerve showed normal motor and sensory action potentials. Follow-up MR neurography demonstrated biceps reinnervation. Taken together, this study reports good long-term results after Oberlin's transfer. MR neurography represents an excellent, noninvasive preoperative planning tool and can be of high value in selected postoperative cases. The combined evaluation of nerves and muscles may help to indicate nerve transfers in delayed cases.
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Bertelli JA, Ghizoni MF. Nerve and Free Gracilis Muscle Transfers for Thumb and Finger Extension Reconstruction in Long-standing Tetraplegia. J Hand Surg Am 2016; 41:e411-e416. [PMID: 27593485 DOI: 10.1016/j.jhsa.2016.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 05/09/2016] [Accepted: 08/01/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE With spinal cord injuries, muscles below the level of the lesion remain innervated despite the absence of volitional control. This persistent innervation protects against denervation atrophy and may allow for nerve transfers to treat long-standing lesions within the spinal cord. We tested the hypothesis that in chronic spinal cord lesions, muscles remained viable for reinnervation. METHODS To test this hypothesis, we operated on 7 patients with tetraplegia to reconstruct thumb and finger extension after a mean interval of 5 years since injury. During surgery, if electrical stimulation of the posterior interosseous nerve (PIN) produced muscle contraction, the nerve to the supinator (NS) was transferred to the PIN. If no contractions were demonstrated, the muscles of the extensor compartment of the forearm were replaced via a free gracilis transfer with innervation supplied by the NS. RESULTS After an average of 26 months, M3 recovery of thumb and finger extension was observed in the 3 upper limbs from the 2 youngest patients who underwent a nerve transfer. None of the free gracilis-treated patients achieved scores above M2. CONCLUSIONS In our youngest patients aged 27 and 34 years, who were operated on 6 years after spinal cord injury, transfer of the NS to the PIN partially restored hand span. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Jayme Augusto Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil.
| | - Marcos Flávio Ghizoni
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil
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