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Liu Y, Massenburg BB, Otten CE, Osorio MB, Lewis SP, Hottovy J, Tse RW. Selective nerve transfers to restore shoulder abduction and flexion in acute flaccid myelitis: A case report. Microsurgery 2024; 44:e31104. [PMID: 37646277 DOI: 10.1002/micr.31104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 07/19/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
Acute flaccid myelitis (AFM) is a polio-like condition predominantly affecting children that is characterized by acute-onset, asymmetric flaccid paralysis, often preceded by a prodromal fever or viral illness. With prompt diagnosis and early surgical referral, nerve transfers may be performed to improve function. Highly selective nerve transfers are ideal to preserve existing functions while targeting specific deficits. In this report, we present a case of a double fascicular nerve transfer of median and ulnar nerve fascicles to the axillary nerve, combined with selective transfer of the spinal accessory nerve to the supraspinatus branch of the suprascapular nerve, performed for a 5-year-old girl who developed AFM after an upper respiratory infection. Six months after the onset of the patient's symptoms, the patient had continued weakness of shoulder flexion and abduction, atrophy of the deltoid, and supraspinatus muscles, though needle electromyography revealed a functioning infraspinatus muscle. The patient had no post-operative complications and at 2 years of postoperative follow up achieved shoulder abduction and flexion Active Movement Scale scores of 7/7 compared to preoperative scores of 2/7, with no loss of function in the donor nerve domains. The patient showed active shoulder abduction against gravity to 90° from 30° preoperatively and shoulder flexion to 180° from 15° preoperatively. This case report shows that highly selective nerve transfers may preserve existing functions while targeting specific deficits. A double fascicular transfer from the median and ulnar nerves to axillary nerve may provide abundant axons for functional recovery.
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Affiliation(s)
- Yusha Liu
- Division of Plastic Surgery, University of Washington, Seattle, Washington, USA
| | | | - Catherine E Otten
- Department of Neurology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Marisa B Osorio
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sarah P Lewis
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Janine Hottovy
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Raymond W Tse
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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Rivera GS, Stokum JA, Dean J, Sadowsky CL, Belzberg AJ, Elrick MJ. Nerve Transfer Surgery in Acute Flaccid Myelitis: Prognostic Factors, Long-Term Outcomes, Comparison With Natural History. Pediatr Neurol 2024; 150:74-81. [PMID: 37981447 PMCID: PMC10894453 DOI: 10.1016/j.pediatrneurol.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/13/2023] [Accepted: 10/26/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Nerve transfer surgery is sometimes offered to patients with acute flaccid myelitis (AFM). The objectives of this study were to evaluate surgical efficacy, assess which clinical and neurophysiological data are valuable for preoperative planning, and report long-term outcomes. METHODS This is a single-center, retrospective case series of patients with AFM who received nerve transfer surgery. All patients had preoperative electromyography and nerve conduction studies (EMG/NCS). Matched control muscles that did not receive nerve transfer surgery were defined in the same cohort. RESULTS Ten patients meeting inclusion criteria received a total of 23 nerve transfers (19 upper extremity, four lower extremity). The mean age at symptom onset was 3.8 years, surgery was 0.5 to 1.25 years after diagnosis, and mean follow-up was 2.3 years (range 1.3 to 4.5 years). Among muscles with preoperative strength Medical Research Council (MRC) grade 0, muscles receiving nerve transfers performed significantly better than those that did not (MRC grade 2.17 ± 0.42 vs 0 ± 0, respectively, P = 0.0001). Preoperative EMG/NCS predicted worse outcomes in recipient muscles with more abundant acute denervation potentials (P = 0.0098). Donor nerves found to be partially denervated performed equally well as unaffected nerves. Limited data suggested functional improvement accompanying strength recovery. CONCLUSIONS Nerve transfer surgery is an effective strategy to restore strength for patients with AFM with persistent, severe motor deficits. Postoperative outcomes in patients with complete paralysis are better than the natural history of disease. This study demonstrates the utility of preoperative clinical and electrophysiological data in guiding patient selection for nerve transfer surgery.
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Affiliation(s)
- Glenn S Rivera
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jesse A Stokum
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet Dean
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Cristina L Sadowsky
- Department of Physical Medicine and Rehabilitation, Kennedy Krieger Institute, Baltimore, Maryland
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew J Elrick
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland.
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Kozlowski J, Linzey JR, Muhlestein WE, Smith BW, Chang KW, Yang LJ. Acute Flaccid Myelitis: Review of Clinical Features, Diagnosis, and Management with Nerve Transfers. Plast Reconstr Surg 2023; 151:85e-98e. [PMID: 36219869 DOI: 10.1097/PRS.0000000000009788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a devastating neurologic condition in children, manifesting as acute limb weakness and/or paralysis. Despite increased awareness of AFM following initiation of U.S. surveillance in 2014, no treatment consensus exists. The purpose of this systematic review was to summarize the most current knowledge regarding AFM epidemiology, cause, clinical features, diagnosis, and supportive and operative management, including nerve transfer. METHODS The authors systematically reviewed the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases to search the keywords ("acute flaccid myelitis"), ('acute flaccid myelitis'/exp OR 'acute flaccid myelitis'), and (Acute AND flaccid AND myelitis). Included articles reported on (1) AFM diagnosis and (2) patient-specific data regarding epidemiology, cause, clinical features, diagnostic features, or management of AFM. RESULTS Ninety-nine articles were included in this review. The precise cause and pathophysiologic mechanism of AFM remain undetermined, but AFM is strongly associated with nonpolio enterovirus infections. Clinical presentation typically comprises preceding viral prodrome, pleocytosis, spinal cord lesions on T2-weighted magnetic resonance imaging, and acute onset of flaccid weakness/paralysis with hyporeflexia in at least one extremity. Supportive care includes medical therapy and rehabilitation. Early studies of nerve transfer for AFM have shown favorable outcomes for patients with persistent weakness. CONCLUSIONS Supportive care and physical therapy are the foundation of a multidisciplinary approach to managing AFM. For patients with persistent limb weakness, nerve transfer has shown promise for improving function in distal muscle groups. Surgeons must consider potential spontaneous recovery, patient selection, donor nerve availability, recipient nerve appropriateness, and procedure timing.
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Dinov D, Donowitz JR. Acute flaccid myelitis a review of the literature. Front Neurol 2022; 13:1034607. [PMID: 36605787 PMCID: PMC9807762 DOI: 10.3389/fneur.2022.1034607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Acute flaccid myelitis (AFM) is a rare neurological disorder that first rose to national attention in 2014. This neurological disorder has a biennial presentation with every other even year being a peak year. Most patients present in childhood 5 days after a prodromal infection. Patients usually present with muscle weakness and hypo or areflexia in the summer or fall months. Clinical outcomes are variable however most patients do not improve. Currently there are no definitive prognostic factors or etiologies found. However, it is thought that enterovirus-D68 (EV-D68) could be a potential component in the pathobiology of AFM. Treatment options are limited with variable options and no consensus. Supportive therapy has been shown to be the most effective thus far. With our review of the literature, we highlight the recent growing evidence of a possible relationship between EV-D68 and AFM. Additionally, we identify the knowledge gaps in AFM with treatment and prognostic factors.
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Affiliation(s)
- Darina Dinov
- Department of Neurology, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States,*Correspondence: Darina Dinov ✉
| | - Jeffrey R. Donowitz
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
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Texakalidis P, Xenos D, Murthy NK, Karras CL, Trybula SJ, Behbahani M, DeCuypere MG, Lam SK, Alden TD. Upper extremity nerve transfers for acute flaccid myelitis: a systematic literature review. Childs Nerv Syst 2022; 38:521-526. [PMID: 34982205 DOI: 10.1007/s00381-021-05419-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/18/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute flaccid myelitis (AFM) is a rare disease that commonly affects young children. AFM's pathophysiology involves loss of lower motor neurons following a viral infection and induces acute asymmetric flaccid paralysis most commonly in the upper extremities. Nerve transfers have emerged as a treatment option for these patients with permanent motor deficits. OBJECTIVE To summarize the literature and report safety and efficacy outcomes following nerve transfers for recovery of shoulder abduction and external rotation, and elbow flexion and extension in pediatric patients with AFM. Recovery of at least antigravity function was defined as a successful outcome. This systematic review was performed according to the PRISMA guidelines. The PubMed, Embase and Cochrane databases were utilized. RESULTS Five studies comprising 44 patients (median age 2.95 years; 71% male), and 93 upper extremity nerve transfers were included. Thirty-eight patients received 65 nerve transfer procedures aiming for recovery of shoulder abduction and/or external rotation with a transfer to the axillary and/or suprascapular nerve. The recovery of shoulder abduction and external rotation was achieved in 40.7% (n = 11/27) and 60% (n = 6/10) of patients, respectively. Time from injury to surgery showed an inverse relationship with the odds for successful recovery (OR: 0.81; 95% CI: 0.64-1.02; p = 0.07); however, statistical significance was not reached. Successful recovery of elbow flexion with a transfer to the musculocutaneous was reported at a rate of 92.3% (n = 12/13). Successful re-innervation of the radial nerve with recovery of elbow extension was found in 75% (n = 6/8) of patients. No complications were reported. CONCLUSIONS Upper extremity nerve transfers appear to be promising and safe for AFM patients. Shoulder abduction is the most challenging upper extremity function to recover. Further studies are warranted to identify whether nerve transfers are associated with superior outcomes when performed earlier.
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Affiliation(s)
- P Texakalidis
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - D Xenos
- Hippokrates General Hospital, Athens, Greece
| | - N K Murthy
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - C L Karras
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - S J Trybula
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - M Behbahani
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - M G DeCuypere
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - S K Lam
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA
| | - T D Alden
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Division of Neurosurgery, Ann & Robert H Lurie Children's Hospital of Chicago, IL, 60611, Chicago, USA.
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Toopchizadeh V, Barzegar M, Ranjbar-Kiyakalayeh S, Shahidzadeh A, Khakbiz S, Jahanshahi A, Jahanjoo F. Clinical presentation, electrodiagnostic findings and outcomes of acute flaccid myelitis: A brief review and case series. J Pediatr Rehabil Med 2022; 15:369-376. [PMID: 35634814 DOI: 10.3233/prm-200798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute flaccid myelitis (AFM) is an acute condition occurring mostly in children. Although affected patients can show a broad spectrum of symptoms, it is mainly characterized by the progressive onset of focal limb weakness, presenting over a period of hours to a week, with or without pain, and spinal cord gray matter involvement on magnetic resonance imaging (MRI). There is compelling evidence to support the role of viruses, in particular enteroviruses. Studies describing electrodiagnostic (EDX) abnormalities and long-term outcomes in AFM are limited. In this report, the clinical presentation, EDX and MRI findings, and long-term outcomes in three children with AFM who presented with progressive and asymmetric weakness of the limbs are described. MRI showed a long segment cervicothoracic lesion with vertical expansion in all three cases. Patients do recover in time, but many continue to have permanent muscle weakness in the worst affected part(s), and complete recovery is rare. Follow-up of these three cases at 18 months demonstrated a partial recovery in the motor system.
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Affiliation(s)
- Vahideh Toopchizadeh
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Barzegar
- Pediatric Health Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sepideh Ranjbar-Kiyakalayeh
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Azadeh Shahidzadeh
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saide Khakbiz
- Physical Medicine and Rehabilitation Research Center, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amirreza Jahanshahi
- Department of Radiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Jahanjoo
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Zuo KJ, Davidge KM. Discussion: Characteristics of Upper Extremity Recovery in Acute Flaccid Myelitis: A Case Series. Plast Reconstr Surg 2021; 147:656-8. [PMID: 33620932 DOI: 10.1097/PRS.0000000000007696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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