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Calotta NA, Shores JT, Tuffaha SH. Adipofascial Perforator Flaps for Peripheral Nerve Resurfacing after External Neurolysis. J Hand Surg Asian Pac Vol 2024; 29:111-117. [PMID: 38494169 DOI: 10.1142/s2424835524500127] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background: External neurolysis is an important approach to treating symptomatic peripheral nerve entrapment. In cases of recurrent neurolysis or particularly extensive neurolysis, a paucity of overlying soft tissue for closure over the freshly liberated nerve presents a challenge to long-term surgical success as primary closure of this tissue may predispose the patient to recalcitrant epineural scarring. We report the intermediate term outcomes of the use of adipofascial perforator flaps as a means of vascularised tissue resurfacing of nerves in these difficult scenarios. Methods: We retrospectively reviewed patients undergoing external neurolysis for painful peripheral nerve lesions who subsequently had soft tissue reconstruction with local adipofascial flaps. Data with regard to age, gender, limb involved, duration of symptoms, number of prior surgeries, operative time, type of flap, vascular basis of flap, duration of follow-up, visual analogue pain score, monofilament sensory testing and complications were collected. Results: We included six patients (four women) with a minimum follow-up period of 17 months (range: 17-25 months). Age ranged from 39 to 60 years of age. Four cases involved the upper extremity and two the lower extremity. Symptoms had been present between 1 and 10 years. All operations utilised a local adipofascial flap perfused by a named perforating vessel emanating from an adjacent axial vessel. Operative time for flap creation and inset was 74 minutes, on average. There was one minor complication owing to superficial wound dehiscence. All patients reported substantial pain relief (≥five-point reduction on visual analogue scale; scores 0-3 at last follow-up) and objective sensory testing demonstrated improvement. Conclusions: Our report pays particular attention to surgical technique that is applicable to both upper and lower extremities in addition to intermediate term safety and pain outcomes. Level of Evidence: Level IV (Therapeutic).
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Affiliation(s)
- Nicholas A Calotta
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Seong D, Choi Y, Choi IC, Lee J, Choi JH, Park JH, Nam JJ, Ju J, Ryoo HJ, Kwak D, Lee J, Kim SG, Kim DH, Park JW, Shin M, Son D. Sticky and Strain-Gradient Artificial Epineurium for Sutureless Nerve Repair in Rodents and Nonhuman Primates. Adv Mater 2024; 36:e2307810. [PMID: 38277680 DOI: 10.1002/adma.202307810] [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] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/09/2023] [Indexed: 01/28/2024]
Abstract
The need for the development of soft materials capable of stably adhering to nerve tissues without any suturing followed by additional damages is at the fore at a time when success in postoperative recovery depends largely on the surgical experience and/or specialized microsuturing skills of the surgeon. Despite fully recognizing such prerequisite conditions, designing the materials with robust adhesion to wet nerves as well as acute/chronic anti-inflammation remains to be resolved. Herein, a sticky and strain-gradient artificial epineurium (SSGAE) that overcomes the most critically challenging aspect for realizing sutureless repair of severely injured nerves is presented. In this regard, the SSGAE with a skin-inspired hierarchical structure entailing strain-gradient layers, anisotropic Janus layers including hydrophobic top and hydrophilic bottom surfaces, and synergistic self-healing capabilities enables immediate and stable neurorrhaphy in both rodent and nonhuman primate models, indicating that the bioinspired materials strategy significantly contributes to translational medicine for effective peripheral nerve repair.
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Affiliation(s)
- Duhwan Seong
- Department of Electrical and Computer Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
| | - Yeonsun Choi
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
- Department of Biomedical Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - In Cheul Choi
- Department of Orthopedic Surgery, College of Medicine, Korea University Anam Hospital, 73, Goryedae-ro, Sungbuk-gu, Seoul, 06334, Republic of Korea
| | - Jaebeom Lee
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - Jae Hyuk Choi
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - Ji Hun Park
- Department of Orthopedic Surgery, College of Medicine, Korea University Anam Hospital, 73, Goryedae-ro, Sungbuk-gu, Seoul, 06334, Republic of Korea
| | - Jae Jun Nam
- Department of Orthopedic Surgery, College of Medicine, Korea University Anam Hospital, 73, Goryedae-ro, Sungbuk-gu, Seoul, 06334, Republic of Korea
| | - Jaewon Ju
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - Hyun Jae Ryoo
- Department of Orthopedic Surgery, College of Medicine, Korea University Anam Hospital, 73, Goryedae-ro, Sungbuk-gu, Seoul, 06334, Republic of Korea
| | - Donghee Kwak
- Department of Orthopedic Surgery, College of Medicine, Korea University Anam Hospital, 73, Goryedae-ro, Sungbuk-gu, Seoul, 06334, Republic of Korea
| | - Joonyeol Lee
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
- Department of Biomedical Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - Seong-Gi Kim
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
- Department of Biomedical Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - Dong Hwee Kim
- Department of Physical Medicine and Rehabilitation, College of Medicine, Korea University Ansan Hospital, Ansan, 15355, Republic of Korea
| | - Jong Woong Park
- Department of Orthopedic Surgery, College of Medicine, Korea University Anam Hospital, 73, Goryedae-ro, Sungbuk-gu, Seoul, 06334, Republic of Korea
| | - Mikyung Shin
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
- Department of Biomedical Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
| | - Donghee Son
- Department of Electrical and Computer Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
- Center for Neuroscience Imaging Research, Institute for Basic Science (IBS), Suwon, 16419, Republic of Korea
- Department of Superintelligence Engineering, Sungkyunkwan University (SKKU), Suwon, 16419, Republic of Korea
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Eberlin KR, Safa B, Buntic R, Rekant MS, Richard MJ, Styron JF, Bendale G, Isaacs J. Usability of Nerve Tape: A Novel Sutureless Nerve Coaptation Device. J Hand Surg Am 2024; 49:346-353. [PMID: 38323947 DOI: 10.1016/j.jhsa.2024.01.001] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/17/2023] [Accepted: 01/03/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE Microsuture neurorrhaphy is technically challenging and has inherent drawbacks. This study evaluated the potential of a novel, sutureless nerve coaptation device to improve efficiency and precision. METHODS Twelve surgeons participated in this study-six attending hand/microsurgeons and six trainees (orthopedic and plastic surgery residents or hand surgery fellows). Twenty-four cadaver arm specimens were used, and nerve repairs were performed at six sites in each specimen-the median and ulnar nerves in the proximal forearm, the median and ulnar nerves in the distal forearm, and the common digital nerves to the second and third web spaces. Each study participant performed nerve repairs at all six injury locations in two different cadaver arms (n = 12 total repairs for each participating surgeon). The nerve repairs were timed, tested for tensile strength, and graded for alignment and technical repair quality. RESULTS A substantial reduction in time was required to perform repairs with the novel coaptation device (1.6 ± 0.8 minutes) compared with microsuture (7.2 ± 3.6 minutes). Device repairs were judged clinically acceptable (scoring "Excellent" or "Good" by most of the expert panel) in 97% of the repairs; the percentage of suture repairs receiving Excellent/Good scores by most of the expert panel was 69.4% for attending surgeons and 36.1% for trainees. The device repairs exhibited a higher average peak tensile force (7.0 ± 3.6 N) compared with suture repairs (2.6 ± 1.6 N). CONCLUSIONS Nerve repairs performed with a novel repair device were performed faster and with higher technical precision than those performed using microsutures. Device repairs had substantially greater tensile strength than microsuture repairs. CLINICAL RELEVANCE The evaluated novel nerve repair device may improve surgical efficiency and nerve repair quality.
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Affiliation(s)
- Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | | | | | - Mark S Rekant
- The Philadelphia Hand to Shoulder Center, Philadelphia, PA
| | - Marc J Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Joseph F Styron
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Geetanjali Bendale
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA
| | - Jonathan Isaacs
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA
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Wee C, Boas S, Coquillard C, Cai Y, Kurlander D, Maasarani S, Leavitt T, Long T, Lineberry K, Khouri J. Combined Targeted Muscle Reinnervation With Regenerative Peripheral Nerve Interfaces Decreases Long-Term Narcotic Use in Amputees: A Case Control Study. Ann Plast Surg 2024; 92:432-436. [PMID: 38527350 DOI: 10.1097/sap.0000000000003836] [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] [Indexed: 03/27/2024]
Abstract
PURPOSE Combined targeted muscle reinnervation with regenerative peripheral nerve interfaces ("TMRpni") is a recently described nerve management strategy that leverages beneficial elements of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) techniques. This study aimed to evaluate the effect of TMRpni on long-term opioid consumption after amputation. We hypothesize that TMRpni decreases chronic opioid consumption in amputees. METHODS This is a retrospective cohort study of all patients who underwent TMRpni between 2019 and 2021. These patients were age-matched at a 1:1 ratio with a control group of patients who underwent amputation without TMRpni. Statistical analysis was performed using SPSS Version 28.0. RESULTS Thirty-one age-matched pairs of patients in the TMRpni and control groups were included. At 30 days after surgery, there was no significant difference in number of patients who required an additional refill of their opioid prescriptions (45% vs 55%, P = 0.45) or patients who continued to actively use opioids (36% vs 42%, P = 0.60). However, at 90 days after surgery, there was a significantly lower number of patients from the TMRpni group who reported continued opioid use compared with the control group (10% vs 32%, P = 0.03). CONCLUSIONS This study demonstrates that TMRpni may translate to decreased rates of chronic opiate use. Continued study is indicated to optimize TMRpni techniques and patient selection and to determine its long-term efficacy.
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Affiliation(s)
- Corinne Wee
- From the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel Boas
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Yida Cai
- Division of Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - David Kurlander
- Department of Plastic Surgery, Rush University Medical Center, Chicago, IL
| | - Samantha Maasarani
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Tripp Leavitt
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, TX
| | - Tobias Long
- Penn State Department of Plastic Surgery, Reading, PA
| | | | - Joseph Khouri
- Division of Plastic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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Bhardwaj P, Sivakumar BS, Venkataramani H, Sabapathy SR. How to do an outside-in/outside-in microsuture for nerve repair. ANZ J Surg 2024; 94:749-751. [PMID: 38105585 DOI: 10.1111/ans.18789] [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: 09/24/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 12/19/2023]
Abstract
Peripheral nerve injuries are common and debilitating. The goals of nerve repair are to accurately approximate the fascicular tissue, whilst ensuring continuous overlying epineurium and eliminating external sprouting of neural tissue. We describe a modification of standard micro-suturing which allows superior epineural eversion and fascicular coaptation.
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Affiliation(s)
- Praveen Bhardwaj
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - Brahman Shankar Sivakumar
- Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Discipline of Surgery, Sydney Medical School, the Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Hari Venkataramani
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
| | - S Raja Sabapathy
- Department of Plastic, Hand and Reconstructive Microsurgery, Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, India
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Pettersen E, Sassu P, Pedrini FA, Granberg H, Reinholdt C, Breyer JM, Roche A, Hart A, Ladak A, Power HA, Leung M, Lo M, Valerio I, Eberlin KR, Ko J, Dumanian GA, Kung TA, Cederna P, Ortiz-Catalan M. Regenerative Peripheral Nerve Interface: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain. J Vis Exp 2024. [PMID: 38557950 DOI: 10.3791/66378] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Surgical procedures, including nerve reconstruction and end-organ muscle reinnervation, have become more prominent in the prosthetic field over the past decade. Primarily developed to increase the functionality of prosthetic limbs, these surgical procedures have also been found to reduce postamputation neuropathic pain. Today, some of these procedures are performed more frequently for the management and prevention of postamputation pain than for prosthetic fitting, indicating a significant need for effective solutions to postamputation pain. One notable emerging procedure in this context is the Regenerative Peripheral Nerve Interface (RPNI). RPNI surgery involves an operative approach that entails splitting the nerve end longitudinally into its main fascicles and implanting these fascicles within free denervated and devascularized muscle grafts. The RPNI procedure takes a proactive stance in addressing freshly cut nerve endings, facilitating painful neuroma prevention and treatment by enabling the nerve to regenerate and innervate an end organ, i.e., the free muscle graft. Retrospective studies have shown RPNI's effectiveness in alleviating postamputation pain and preventing the formation of painful neuromas. The increasing frequency of utilization of this approach has also given rise to variations in the technique. This article aims to provide a step-by-step description of the RPNI procedure, which will serve as the standardized procedure employed in an international, randomized controlled trial (ClinicalTrials.gov, NCT05009394). In this trial, RPNI is compared to two other surgical procedures for postamputation pain management, specifically, Targeted Muscle Reinnervation (TMR) and neuroma excision coupled with intra-muscular transposition and burying.
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Affiliation(s)
- Emily Pettersen
- Center for Bionics and Pain Research; Center for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital; Department of Electrical Engineering, Chalmers University of Technology; Bionics Institute
| | - Paolo Sassu
- IV Clinica Ortoplastica, IRCCS Istituto Ortopedico Rizzoli
| | - Francesca Alice Pedrini
- Center for Bionics and Pain Research; IV Clinica Ortoplastica, IRCCS Istituto Ortopedico Rizzoli
| | - Hannes Granberg
- Center for Bionics and Pain Research; Center for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital
| | - Carina Reinholdt
- Center for Advanced Reconstruction of Extremities, Sahlgrenska University Hospital; Department of Hand Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital
| | | | - Aidan Roche
- College of Medicine and Veterinary Medicine, The Queen's Medical Research Institute, The University of Edinburgh
| | - Andrew Hart
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary; College of Medicine, Veterinary & Life Sciences, The University of Glasgow
| | - Adil Ladak
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
| | - Hollie A Power
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
| | - Michael Leung
- Plastics and Reconstructive Surgery, Dandenong Hospital, Monash Health
| | - Michael Lo
- Plastics and Reconstructive Surgery, Dandenong Hospital, Monash Health
| | - Ian Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital & Harvard Medical School
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital & Harvard Medical School
| | - Jason Ko
- Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine
| | - Gregory A Dumanian
- Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine
| | - Theodore A Kung
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine
| | - Paul Cederna
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine
| | - Max Ortiz-Catalan
- Center for Bionics and Pain Research; Bionics Institute; Medical Bionics Department, University of Melbourne; Prometei Pain Rehabilitation Center;
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Palafox D. Regenerative Peripheral Nerve Interface Surgery and Targeted Muscle Reinnervation for the Treatment of Chronic Pain in Limb Amputees. J Am Coll Surg 2024; 238:359-360. [PMID: 37921366 DOI: 10.1097/xcs.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
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8
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Megerle K, Bahm J. [Peripheral Nerve Surgery]. HANDCHIR MIKROCHIR P 2024; 56:6. [PMID: 38508201 DOI: 10.1055/a-2168-2239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
In den letzten dreißig Jahren hat sich die Chirurgie an peripheren Nerven vermehrt zu
einem Schwerpunkt entwickelt, der Kolleginnen und Kollegen aus der Neurochirurgie,
Orthopädie, Plastischen und Handchirurgie anspricht. Die Interaktion der
chirurgischen Fächer mit Neurologen, Neuropathologen und Neuroradiologen ist dabei
sehr wichtig.
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Glaser JJ, Aman M, Böcker AH, Thielen M, Harhaus L. [Nerve Transfers in Peripheral Nerve Lesions]. HANDCHIR MIKROCHIR P 2024; 56:49-54. [PMID: 38316412 DOI: 10.1055/a-2228-7062] [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] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Lesions of peripheral nerves of the upper extremities often lead to persistent, serious limitations in motor function and sensory perception. Affected patients suffer from both private and professional restrictions associated with long-term physical, psychological and socioeconomic consequences. INDICATION An early indication for a nerve transfer shortens the reinnervation distance and improves the growing of motor and sensory axons into the target organ to facilitate early mobility and sensitivity. When planning the timepoint of the surgical procedure, the distance to be covered by reinnervation as well as the morbidities of donor nerves must be considered individually. RESULTS Nerve transfers can achieve earlier and safer reinnervation to improve motor and sensory functions after nerve injuries in the upper extremity.
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Affiliation(s)
- Julia Janine Glaser
- Abteilung Handchirurgie, Periphere Nervenchirurgie, Rehabilitation, BG Klinik Ludwigshafen, Germany
| | - Martin Aman
- Abteilung Handchirurgie, Periphere Nervenchirurgie, Rehabilitation, BG Klinik Ludwigshafen, Germany
| | - Arne Hendrik Böcker
- Abteilung Handchirurgie, Periphere Nervenchirurgie, Rehabilitation, BG Klinik Ludwigshafen, Germany
| | - Mirjam Thielen
- Abteilung Handchirurgie, Periphere Nervenchirurgie, Rehabilitation, BG Klinik Ludwigshafen, Germany
| | - Leila Harhaus
- Abteilung Handchirurgie, Periphere Nervenchirurgie, Rehabilitation, BG Klinik Ludwigshafen, Germany
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Bertelli JA, Rosa ICN, Ghizoni MF. Retrograde peripheral nerve regeneration from sensory to motor pathways in rats: a new experimental concept in nerve repair. Neurol Res 2024; 46:125-131. [PMID: 37729085 DOI: 10.1080/01616412.2023.2258039] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/03/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND The polarity of nerve grafts does not interfere with axon growth. Our goal was to investigate whether axons can regenerate in a retrograde fashion within sensory pathways and then extend into motor pathways, leading to muscle reinnervation. METHODS Fifty-four rats were randomized into four groups. In Group 1, the ulnar nerve was connected end-to-end to the superficial radial nerve after neurectomy of the radial nerve in the axilla. In Group 2, the ulnar nerve was connected end-to-end to the radial nerve distal to the humerus; the radial nerve then was divided in the axilla. In Group 3, the radial nerve was divided in the axilla, but no nerve reconstruction was performed. In Group 4, the radial nerve was crushed in the axilla. Over 6 months, we behaviorally assessed the recovery of toe spread in the right operated-upon forepaw by lifting the rat by its tail and lowering it onto a flat surface. Six months after surgery, rats underwent reoperation, nerve transfers were tested electrophysiologically, and the posterior interosseous nerve (PIN) was removed for histological evaluation. RESULTS Rats in the crush group recovered toe spread between 5 and 8 days after surgery. Rats with nerve transfers demonstrated electrophysiological and histological findings of nerve regeneration but no behavioral recovery. CONCLUSIONS Ulnar nerve axons regrew into the superficial radial nerve and then into the PIN to reinnervate the extensor digitorum communis. We were unable to demonstrate behavioral recovery because rats cannot readapt to cross-nerve transfer.
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Affiliation(s)
- Jayme A Bertelli
- Department of Surgery in lieu of Department of Surgical Techniques, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Isadora Carvalho Nunes Rosa
- Center of Biological and Health Sciences, University of the South of Santa Catarina (UNISUL), Tubarão, Santa Catarina, Brazil
| | - Marcos F Ghizoni
- Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (UNISUL), Tubarão, Santa Catarina, Brazil
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Minzenmay L, Antoniadis G, Paľa A, Bäzner UM, Knoll A, Petkov M, Wirtz CR, Pedro MT. The impact of SARS-Covid-19 pandemic on peripheral nerve surgery - A single centre report. Clin Neurol Neurosurg 2024; 237:108124. [PMID: 38266330 DOI: 10.1016/j.clineuro.2024.108124] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE SARS-Cov-19 pandemic totally changed daily routine work in German hospitals. As hospital capacity was reduced, many surgeries were postponed or even cancelled. On March 25th 2020 the German Society of Neurosurgery (DGNC) published a statement in which urgent non-elective surgeries were defined for each neurosurgical domain, whereas elective interventions were deferred. The present work examines the impact of these Covid strategies focusing on patients with peripheral lesions who were conducted to our department during this period of time. METHODS All patients who underwent any peripheral nerve surgery at our department from January 2018 until December 2022, were included. The complete range of surgeries including peripheral nerve lesions was examined encompassing compression syndromes, traumatic lesions of brachial plexus, traumatic lesions and tumors of single peripheral nerves. The numbers of surgical procedures were compared before, during and after pandemic. Pearson correlation coefficient was analysed. RESULTS From 2018 to 2022 the total number of surgical procedures involving peripheral nerves included 2422 procedures. Compression syndromes made up the largest proportion (1433 operations, 59%), followed by peripheral nerve lesions (445 operations, 18%), peripheral nerve tumors (344 operations, 14%) and lesions of the brachial plexus (142 operations, 6%). The average was 40,5 interventions per month, the range was 7-63. Two declines in the number of peripheral nerve surgeries were noted during this period. The first was in April and May 2020 with an average drop of 65% and 41% respectively. In these months the average number of operations was 37. The second decrease was from October 2021 until January 2022, where number of surgeries was reduced by 16%, 36%, 83% and 18% with an average number of 50 operations. Both declines showed a significant and strong correlation with the lower number of compression syndrome treatments (r = 0.952, p < 0.001 and r = 0.968, p < 0.001), while no drop and no significant correlation was found in the treatment of traumatic peripheral nerve injuries (p = 0.769, r = 0.095 and p = 0.243, r = 0.366) and traumatic brachial plexus injuries (p = 0.787, r = 0.088 and p = 0.780, r = 0.09). A weak significant correlation was seen in the treatment numbers of peripheral nerve tumors (p = 0.017, r = 0.672 and p = 0.015, r = 0.67). CONCLUSION Covid-19 pandemic lead to a significant decrease in the number of nerve decompressions, since, according to the German Society of Neurosurgery, those were considered as elective surgeries.
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Affiliation(s)
- Lena Minzenmay
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany.
| | - Gregor Antoniadis
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Andrej Paľa
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Ute Marlies Bäzner
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Andreas Knoll
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | - Martin Petkov
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
| | | | - Maria Teresa Pedro
- University of Ulm, Department of Neurosurgery, Lindenallee 2, 89312 Günzburg, Germany
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Assmus H, Antoniadis G, Heinen C, Kneser U, Bahm J. ["Nerve Surgery" In German-Speaking Countries - Starting With The Nerve Club Up To A Certificate]. HANDCHIR MIKROCHIR P 2024; 56:7-10. [PMID: 38508202 DOI: 10.1055/a-2241-2809] [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] [Indexed: 03/22/2024] Open
Abstract
We present the Nerve Club, a community of colleagues originating from german-speaking countries and dedicated to those working in or outside surgery with interest in the peripheral nerve. This article reviews the club´s history and specific characteristics and activities, and highlights the concept of a certificate in nerve surgery. We have annual club meetings and organize every two years a plexus symposium. Also exists a scientific publication award and cooperation with an online based journal dedicated to medical publications in the field of nerve surgery.
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Affiliation(s)
| | | | - Christian Heinen
- Medizinisches Versorgungszentrum am Christlichen Krankenhaus Fachbereich Neurochirurgie, Quakenbrück
| | - Ulrich Kneser
- Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwigshafen
| | - Jörg Bahm
- Klinik für Plastische, Hand und Verbrennungschirurgie am Universitätsklinikum der RWTH Aachen, Aachen
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Karcz M, Gharibo C. Peripheral Nervous System Pain Modulation. Curr Neuropharmacol 2024; 22:65-71. [PMID: 37534790 DOI: 10.2174/1570159x21666230803100400] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/09/2023] [Accepted: 04/26/2023] [Indexed: 08/04/2023] Open
Abstract
The percutaneous technique of electrode insertion in the vicinity of the greater occipital nerves to treat occipital neuralgia was first described in the 1990s by Weiner and Reed. This subsequently stimulated awareness of peripheral nerve stimulation (PNS). The more recent advent emergence of a minimally invasive percutaneous approach by way of using ultrasound has further increased the interest in PNS as a viable alternative to more invasive techniques. PNS has become more popular recently and is increasingly used to treat various pain conditions. Its foundation is fundamentally based on the gate control theory, although the precise mechanism underlying its analgesic effect is still indefinite. Studies have demonstrated the peripheral and central analgesic mechanisms of PNS by modulating the inflammatory pathways, the autonomic nervous system, the endogenous pain inhibition pathways, and the involvement of the cortical and subcortical areas. Peripheral nerve stimulation exhibits its neuromodulatory effect both peripherally and centrally. Further understanding of the modulation of PNS mechanisms can help guide stimulation approaches and parameters to optimize the use of PNS. his chapter aims to review the background and mechanisms of PNS modulation. PNS is becoming one of the most diverse therapies in neuromodulation due to rapid evolution and expansion. It is an attractive option for clinicians due to the simplicity and versatility of procedures that can be combined with other neuromodulation treatments or used alone. It has a distinct role in the modulation of functional conditions.
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Affiliation(s)
- Marcin Karcz
- Division of Pain Medicine, Department of Anesthesia, New York University Grossman School of Medicine, New York, NY, USA
| | - Christopher Gharibo
- Division of Pain Medicine, Department of Anesthesia, New York University Grossman School of Medicine, New York, NY, USA
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Sisti A, Uygur S, Lopez-Schultz SD, Konofaos P. Nerve Capping Techniques for Neuroma Management: A Comprehensive Literature Review. Ann Plast Surg 2024; 92:106-119. [PMID: 37962245 DOI: 10.1097/sap.0000000000003714] [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] [Indexed: 11/15/2023]
Abstract
BACKGROUND/AIM OF THE STUDY Nerve capping is a method of neuroma treatment or prevention that consists of the transplantation of a proximal nerve stump into an autograft or other material cap, after surgical removal of the neuroma or transection of the nerve. The aim was to reduce neuroma formation and symptoms by preventing neuronal adhesions and scar tissue. In this narrative literature review, we summarize the studies that have investigated the effectiveness of nerve capping for neuroma management to provide clarity and update the clinician's knowledge on the topic. METHODS A systematic electronic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was performed in the PubMed database combining "neuroma," "nerve," "capping," "conduit," "treatment," "management," "wrap," "tube," and "surgery" as search terms. English-language clinical studies on humans and animals that described nerve capping as a treatment/prevention technique for neuromas were then selected based on a full-text article review. The data from the included studies were compiled based on the technique and material used for nerve capping, and technique and outcomes were reviewed. RESULTS We found 10 applicable human studies from our literature search. Several capping materials were described: epineurium, nerve, muscle, collagen nerve conduit, Neurocap (synthetic copolymer of lactide and caprolactone, which is biocompatible and resorbable), silicone rubber, and collagen. Overall, 146 patients were treated in the clinical studies. After surgery, many patients were completely pain-free or had considerable improvement in pain scores, whereas some patients did not have improvement or were not satisfied after the procedure. Nerve capping was used in 18 preclinical animal studies, using a variety of capping materials including autologous tissues, silicone, and synthetic nanofibers. Preclinical studies demonstrated successful reduction in rates of neuroma formation. CONCLUSIONS Nerve capping has undergone major advancements since its beginnings and is now a useful option for the treatment or prevention of neuromas. As knowledge of peripheral nerve injuries and neuroma prevention grows, the criterion standard neuroprotective material for enhancement of nerve regeneration can be identified and applied to produce reliable surgical outcomes.
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Affiliation(s)
- Andrea Sisti
- Division of General Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
- Shriners Hospital for Children, Galveston, TX
| | - Safak Uygur
- Division of Plastic, Reconstructive and Hand Surgery, Department of Surgery, West Virginia University, Morgantown, WV
| | | | - Petros Konofaos
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
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Elkholy AR, Rezk EM, Shabaan N, Elkhouly RM, Shamhoot EA. The role of preoperative ultrasound in the management of peripheral nerve injuries. Clin Neurol Neurosurg 2024; 236:108083. [PMID: 38104445 DOI: 10.1016/j.clineuro.2023.108083] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Peripheral nerve injury refers to any damage or trauma to the nerves located outside the central nervous system. Ultrasonography is a reliable, cheap, and minimally invasive method in clinical practice to give physicians useful information about nerve injury. OBJECTIVES to assess the power of ultrasound in determining the presence, localization, and extent of neural damage in patients with clinical evidence of peripheral nerve lesions before surgery. METHODS This cross-sectional study was conducted on 78 patients (56 females and 22 males, aged from 9 to 52 years) who had different pathologies including entrapment, tumoral, post-traumatic, and post-surgical nerve injuries at the Neurosurgery and Physical Medicine, Rheumatology, and Rehabilitation Departments, Tanta University Hospitals. All studied patients had preoperative evaluation; neurological examination, electrodiagnostic studies, and sonographic examinations with linear array transducers (frequencies ranging from 7.5 to 16 MHz). RESULTS The most common pathological condition was entrapment neuropathy (39 patients) (50%). Ultrasound complemented the electrodiagnostic studies by determining the site of entrapment manifested by increased mean maximum cross-sectional area of the nerve proximal to the site of entrapment and nerve hypoechogenicity. In post-traumatic and iatrogenic neuropathies (35 patients) (44.9%), the ultrasound finding revealed neuroma in continuity in nine cases (11.5%), complete neurotmesis with stump neuroma in eighteen patients (23.1%), and eight cases (10.3%) showed perineural adhesion. In all cases, the nerve was hypoechoic at the site of injury. The presence of hyperechoic fibrous tissue could indicate perineural adhesion and the necessity for neurolysis. This study also included three (3.8%) cases had schwannoma, and one case (1.3%) had neurofibroma. Ultrasound was used to confirm the diagnosis by determining the tumor's size and vascular supply. CONCLUSIONS Ultrasonography is a diagnostic and surgical planning tool that is becoming more and more useful for the management of peripheral nerve injuries. Its high resolution and real-time capability provide safe and cost-effective scans that aid in determining the extent of injuries. For patients with peripheral nerve injuries, ultrasound is advised to be added to the routine clinical and neurophysiological evaluation. It is also advised to use ultrasound as a first-line imaging modality for tumors thought to be of nerve origin.
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Affiliation(s)
- Ahmed R Elkholy
- Department of Neurosurgery, Faculty of Medicine, Tanta University, Egypt
| | - Essam M Rezk
- Department of Neurosurgery, Faculty of Medicine, Tanta University, Egypt.
| | - Nehal Shabaan
- Department of Neurosurgery, Faculty of Medicine, Tanta University, Egypt
| | - Radwa M Elkhouly
- Department of Rheumatology, Rehabilitation and Physical Medicine, Faculty of Medicine, Tanta University, Egypt
| | - Ebrahim A Shamhoot
- Department of Neurosurgery, Faculty of Medicine, Tanta University, Egypt
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16
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Stoy C, Beredjiklian P, Kreitz T, Tulipan J. Postoperative Functional Analysis of Double Crush Versus Single Peripheral Nerve Decompression: A Retrospective Study. Hand (N Y) 2024; 19:143-148. [PMID: 35272535 PMCID: PMC10786109 DOI: 10.1177/15589447211038681] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Double crush (DC) syndrome patients presenting with C6-7 radiculopathy and median nerve compression in the carpal tunnel report greater nerve irritability and weakness postdecompression than isolated peripheral nerve decompression. We hypothesize that patient-reported outcome is inferior following release at both cervical spine and wrist versus a single site of decompression. METHODS Patients that underwent either anterior cervical decompression and fusion (ACDF) for C6-C7 radiculopathy, carpal tunnel release (CTR), or both within 5 years (DC) were identified. A total of 477 patients were analyzed (157 DC, 203 CTR, and 117 ACDF). Post-operative outcome Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Neck Disability Index, and visual analog scale (VAS) scores were collected at an average of 2 years postoperatively. RESULTS QuickDASH scores were higher in the DC group versus CTR group (36 vs 22, P < .0002). Postoperative disability in the ACDF group was significantly higher than the DC group (50 vs 36, P < .017). There were no differences between ACDF and DC groups in arm pain intensity, but the CTR group demonstrated significantly greater arm pain intensity than the DC group (5.7 vs 3.6, 10-point scale, P < .01). CONCLUSIONS Patients undergoing ACDF and CTR have greater postoperative disability than those undergoing CTR alone, but less postoperative functional disability and pain than ACDF alone, indicating cervical radiculopathy may contribute a greater proportion of long-term disability postoperatively. Additionally, CTR had greater postoperative arm pain than DC patients, potentially indicating high rates of undiagnosed cervical radiculopathy or other sources of arm pain in these patients.
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Affiliation(s)
- Conrad Stoy
- Drexel University College of Medicine, Philadelphia, PA, USA
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | | | - Tyler Kreitz
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Jacob Tulipan
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
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17
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Zhang M, An H, Gu Z, Zhang YC, Wan T, Jiang HR, Zhang FS, Jiang BG, Han N, Wen YQ, Zhang PX. Multifunctional wet-adhesive chitosan/acrylic conduit for sutureless repair of peripheral nerve injuries. Int J Biol Macromol 2023; 253:126793. [PMID: 37709238 DOI: 10.1016/j.ijbiomac.2023.126793] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Abstract
The incidence of peripheral nerve injury (PNI) is high worldwide, and a poor prognosis is common. Surgical closure and repair of the affected area are crucial to ensure the effective treatment of peripheral nerve injuries. Despite being the standard treatment approach, reliance on sutures to seal the severed nerve ends introduces several limitations and restrictions. This technique is intricate and time-consuming, and the application of threading and punctate sutures may lead to tissue damage and heightened tension concentrations, thus increasing the risk of fixation failure and local inflammation. This study aimed to develop easily implantable chitosan-based peripheral nerve repair conduits that combine acrylic acid and cleavable N-hydroxysuccinimide to reduce nerve damage during repair. In ex vivo tissue adhesion tests, the conduit achieved maximal interfacial toughness of 705 J m-2 ± 30 J m-2, allowing continuous bridging of the severed nerve ends. Adhesive repair significantly reduces local inflammation caused by conventional sutures, and the positive charge of chitosan disrupts the bacterial cell wall and reduces implant-related infections. This promises to open new avenues for sutureless nerve repair and reliable medical implants.
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Affiliation(s)
- Meng Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
| | - Heng An
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Daxing Research Institute, School of Chemistry & Biological Engineering, University of Science & Technology Beijing, Beijing 100083, China.
| | - Zhen Gu
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Daxing Research Institute, School of Chemistry & Biological Engineering, University of Science & Technology Beijing, Beijing 100083, China.
| | - Yi-Chong Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
| | - Teng Wan
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
| | - Hao-Ran Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
| | - Feng-Shi Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
| | - Bao-Guo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
| | - Na Han
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
| | - Yong-Qiang Wen
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Daxing Research Institute, School of Chemistry & Biological Engineering, University of Science & Technology Beijing, Beijing 100083, China.
| | - Pei-Xun Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration, Peking University, National Center for Trauma Medicine, Beijing 100044, China.
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Abstract
SUMMARY Neuralgic amyotrophy (NA) is a disease affecting peripheral nerves. Treatment has historically been conservative, as the natural course of the disease was thought to be self-limiting. Recent work has demonstrated that as many as two-thirds of people with NA have persistent pain, fatigue, or weakness. At the authors' center, supercharged end-to-side (SETS) nerve transfers are commonly performed in patients with NA to optimize motor recovery while allowing for native axonal regrowth. The authors describe the technique and clinical outcomes of patients with NA affecting the anterior interosseous nerve (AIN) who were treated with SETS nerve transfer from extensor carpi radialis brevis to AIN. Ten patients (90% male; mean age, 51.3 ± 9.7 years) underwent extensor carpi radialis brevis-to-AIN transfer at a mean period of 6.4 ± 1.4 months after onset of symptoms. Mean postoperative follow-up duration was 14.8 ± 3.2 months. Before surgery, all patients demonstrated clinically significant weakness in the flexor pollicis longus (FPL), flexor digitorum profundus muscle to the index finger (FDP2), or both. FPL strength improved from a median Medical Research Council (MRC) grade of 1.5 to 4 ( P = 0.011) and FDP2 strength improved from a median MRC grade of 1 to 5 ( P = 0.016). A postoperative MRC grade of 4 or greater was achieved in nine of 10 (90%) FPL and 10 of 10 (100%) FDP muscles. This is the first report of SETS nerve transfer for the treatment of NA. The outcomes of this work suggest that SETS nerve transfers may be an option to optimize motor outcomes in patients with NA. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Ogi Solaja
- From the Divisions of Plastic and Reconstructive Surgery
| | | | - Linden K Head
- From the Divisions of Plastic and Reconstructive Surgery
| | - Gerald K Wolff
- Physical Medicine and Rehabilitation, University of Ottawa
| | - Kirsty U Boyd
- From the Divisions of Plastic and Reconstructive Surgery
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De la Fuente Hagopian A, Farhat S, Guadarrama-Sistos Vazquez S, Reddy NK, Bombardelli J, Echo A. Ten steps for proper peripheral nerve handling during inguinal hernia surgery. Hernia 2023; 27:1607-1610. [PMID: 37548798 DOI: 10.1007/s10029-023-02809-9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 05/21/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Post-inguinal pain after a hernia surgery is prevalent and can be quite frustrating for the surgeon and patient alike. There are several sources for possible post-operative inguinal pain after a successful hernia repair; however, in the setting where a recurrent inguinal hernia is not present, it is likely related to the nerves in the inguinal canal or pelvis. Chronic inguinal groin pain after hernia repairs have been reported in a high percentage of patients following inguinal hernia surgery despite being one of the most common procedures performed annually in the USA and worldwide. MATERIALS AND METHODS We present ten of the basic concepts utilized by peripheral nerve surgeons to limit nerve injury, which can easily be applied to open inguinal hernia surgery with or without mesh, starting with the firm understanding of the inguinal anatomy to addressing the nerves, meticulous placement of the mesh and the active revision of the surrounding structures and nerve position before closure. CONCLUSIONS Understanding the proper handling of the inguinal nerves during hernia surgery can decrease the incidence of post-operative chronic pain by employing microsurgical concepts to day-to-day surgical procedures and prevent complications in an extensive set of patients.
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Affiliation(s)
- A De la Fuente Hagopian
- The Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin, Suite 2200, Scurlock Tower, Houston, TX, 77030, USA
| | - S Farhat
- The Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin, Suite 2200, Scurlock Tower, Houston, TX, 77030, USA
| | - S Guadarrama-Sistos Vazquez
- The Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin, Suite 2200, Scurlock Tower, Houston, TX, 77030, USA
| | - N K Reddy
- Engineering Medicine (EnMed), Texas A&M Health Science Center, Houston, TX, USA
| | - J Bombardelli
- General Surgery Department, Houston Methodist Hospital, Houston, TX, USA
| | - A Echo
- The Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, 6560 Fannin, Suite 2200, Scurlock Tower, Houston, TX, 77030, USA.
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Orlando NA, Qiu CS, ElNemer W, Tuffaha SH. Google Trends Analysis of Peripheral Nerve Disease and Surgery. World Neurosurg 2023; 180:e135-e141. [PMID: 37690579 DOI: 10.1016/j.wneu.2023.09.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Despite advances in the surgical management of peripheral nerve pathologies over the past several decades, it is unknown how public awareness of these procedures has changed. We hypothesize that Google searches for peripheral nerve surgery have increased over time. METHODS Google Trends was queried for search volumes of a list of 40 keywords related to the following topics in peripheral nerve surgery: spasticity, nerve injury, prosthetics, and nerve pain. Monthly relative search volume over the first 5 years of the study period (2010-2014) was compared with that of the last 5 years (2018-2022) of the study period. RESULTS Search volumes for keywords "nerve injury," "nerve laceration," "peripheral nerve injury," "nerve repair," "nerve transfer", "neuroma," "neuroma pain," "nerve pain," "nerve pain surgery," and "neuroma pain surgery" all increased more than 10% points in relative search volume over the study period (P < 0.0001 for each keyword). In contrast, searches for "rhizotomy," "spasticity surgery," "targeted muscle reinnervation," "bionic arm," and "myoelectric prosthesis" either decreased or remained stable. Technical terms such as "selective neurectomy," "hyperselective neurectomy," "regenerative peripheral nerve interface," and "regenerative peripheral nerve interface surgery" did not have adequate search volume to be reported by Google Trends. CONCLUSIONS The increase in Google searches related to nerve injury and pain between 2010 and 2022 may reflect increasing public recognition of these clinical entities and surgical techniques addressing them. Technical terms relating to nerve pain are infrequently searched, surgeons should use plain English terms for online discovery. Interest in spasticity and myoelectric prosthetics remains stable, indicating an opportunity for better public outreach.
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Affiliation(s)
- Nicholas A Orlando
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cecil S Qiu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William ElNemer
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Küenzlen L, Wallmichrath JC, Küntscher MV, Rothenberger J, Laback C, Schaefer DJ, Schaff J, Bozkurt A, Djedovic G, Langer S, Hirsch T, Rieger U. [Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. HANDCHIR MIKROCHIR P 2023; 55:427-436. [PMID: 37783212 DOI: 10.1055/a-2134-5891] [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] [Indexed: 10/04/2023] Open
Abstract
The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.
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Affiliation(s)
- Lara Küenzlen
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | | | - Markus V Küntscher
- Plastische Chirurgie, Privatpraxis für Plastische & Ästhetische Chirurgie, Hohen Neuendorf, Germany
| | - Jens Rothenberger
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Christian Laback
- Klinische Abteilung für plastische, ästhetische und rekonstruktive Chirurgie, Medizinische Universität Graz, Graz, Austria
| | | | | | - Ahmet Bozkurt
- Klinik für Plastische, Ästhetische und Handchirurgie , HELIOS Universitatsklinikum Wuppertal, Wuppertal, Germany
| | - Gabriel Djedovic
- Abteilung für Plastische, Ästhetische und Rekonstruktive Chirurgie, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Stefan Langer
- Sektion Plastische, Ästhetische und Spezielle Handchirurgie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Tobias Hirsch
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Fachklinik Hornheide eV, Munster, Germany
- Abteilung für Plastische Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirugie, Universitätsklinikum Münster, Munster, Germany
| | - Ulrich Rieger
- Klinik für Plastische und Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
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22
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Roubaud MS, Hassan AM, Shin A, Mericli AF, Adelman DM, Hagan K, Popat K, Lin P, Moon B, Lewis VO. Outcomes of Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces for Chronic Pain Control in the Oncologic Amputee Population. J Am Coll Surg 2023; 237:644-654. [PMID: 37278406 DOI: 10.1097/xcs.0000000000000778] [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] [Indexed: 06/07/2023]
Abstract
BACKGROUND Outcomes of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) in the oncologic population are limited. We sought to examine the safety and effectiveness of TMR and RPNI in controlling postamputation pain in the oncologic population. STUDY DESIGN A retrospective cohort study of consecutive patients who underwent oncologic amputation followed by immediate TMR or RPNI was conducted from November 2018 to May 2022. The primary study outcome was postamputation pain, assessed using the Numeric Pain Scale and Patient-Reported Outcomes Measurement Information System (PROMIS) for residual limb pain (RLP) and phantom limb pain (PLP). Secondary outcomes included postoperative complications, tumor recurrence, and opioid use. RESULTS Sixty-three patients were evaluated for a mean follow-up period of 11.3 months. The majority of patients (65.1%) had a history of previous limb salvage. At final follow-up, patients had an average Numeric Pain Scale score for RLP of 1.3 ± 2.2 and for PLP, 1.9 ± 2.6. The final average raw PROMIS measures were pain intensity 6.2 ± 2.9 (T-score 43.5), pain interference 14.6 ± 8.3 (T-score 55.0), and pain behavior 39.0 ± 22.1 (T-score 53.4). Patient opioid use decreased from 85.7% preoperatively to 37.7% postoperatively and morphine milligram equivalents decreased from a mean of 52.4 ± 53.0 preoperatively to 20.2 ± 38.4 postoperatively. CONCLUSIONS In the oncologic population TMR and RPNI are safe surgical techniques associated with significant reductions in RLP, PLP, and improvements in patient-reported outcomes. This study provides evidence for the routine incorporation of TMR and RPNI in the multidisciplinary care of oncologic amputees.
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Affiliation(s)
- Margaret S Roubaud
- From the Departments of Plastic and Reconstructive Surgery (Roubaud, Hassan, Mericli, Adelman), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Abbas M Hassan
- From the Departments of Plastic and Reconstructive Surgery (Roubaud, Hassan, Mericli, Adelman), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ashley Shin
- University of Texas, McGovern Medical School, Houston, TX (Shin)
| | - Alexander F Mericli
- From the Departments of Plastic and Reconstructive Surgery (Roubaud, Hassan, Mericli, Adelman), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David M Adelman
- From the Departments of Plastic and Reconstructive Surgery (Roubaud, Hassan, Mericli, Adelman), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katherine Hagan
- Anesthesiology and Perioperative Medicine (Hagan, Popat), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Keyuri Popat
- Anesthesiology and Perioperative Medicine (Hagan, Popat), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Patrick Lin
- Orthopedic Surgery (Lin, Moon, Lewis), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bryan Moon
- Orthopedic Surgery (Lin, Moon, Lewis), The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Valerae O Lewis
- Orthopedic Surgery (Lin, Moon, Lewis), The University of Texas MD Anderson Cancer Center, Houston, TX
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Ruan T, Jones AC. Superior Cluneal Nerve Entrapment Syndrome: Thought to Be Spondylolysis. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202310000-00008. [PMID: 37852245 PMCID: PMC10584293 DOI: 10.5435/jaaosglobal-d-23-00091] [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: 04/30/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 10/20/2023]
Abstract
A rare but typically overlooked diagnosis in the orthopaedic surgery community is superior cluneal nerve (SCN) entrapment syndrome. The cluneal nerves function as purely sensory fibers, and the SCNs provide cutaneous innervation to the posterior parasacral, gluteal, and posterolateral thigh regions. When irritated, this syndrome can cause acute and chronic lower back pain and lower extremity symptoms. A 14-year-old adolescent girl presented to the clinic for an evaluation of pain in the right side of her lower back. The patient's physical examination showed tenderness to palpation on the right posterior iliac crest seven centimeters from the midline. Her neurologic examination demonstrated normal deep tendon reflexes, muscle strength, and sensation in the L2-S1 dermatomal distribution. Although imaging showed evidence of a left L5 spondylolysis, she responded positively to a steroid injection over the posterior iliac crest but negatively to one over the L5 pars defect. She later underwent a right SCN decompression surgery. After the procedure, she reported at least 90% improvement in her pain and rated it as a one in severity, on a scale of 0 to 10. Research regarding SCN entrapment syndrome has increased in the past several years. However, most of these studies are limited to the adult population. Therefore, more reports highlighting the potential for this syndrome in adolescents are needed as well.
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Affiliation(s)
- Tiffany Ruan
- From the College of Osteopathic Medicine, Kansas City University, Kansas City, MO (Ms. Ruan), and the Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Dr. Jones)
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Chu TH, Alzahrani S, McConnachie A, Lasaleta N, Kalifa A, Pathiyil R, Midha R. Perineurial Window is Critical for Experimental Reverse End-to-Side Nerve Transfer. Neurosurgery 2023; 93:952-960. [PMID: 37018413 DOI: 10.1227/neu.0000000000002481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/08/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The depth of connective tissue window in the side of a recipient nerve in reverse end-to-side transfers (RETS) remains controversial. OBJECTIVE To test whether the depth of connective tissue disruption influences the efficiency of donor axonal regeneration in the context of RETS. METHODS Sprague-Dawley rats (n = 24) were assigned to 1 of the 3 groups for obturator nerve to motor femoral nerve RETS: group 1, without epineurium opening; group 2, with epineurium only opening; and group 3, with epineurium and perineurium opening. Triple retrograde labeling was used to assess the number of motor neurons that had regenerated into the recipient motor femoral branch. Thy1-GFP rats (n = 8) were also used to visualize the regeneration pathways in the nerve transfer networks at 2- and 8-week time point using light sheet fluorescence microscopy. RESULTS The number of retrogradely labeled motor neurons that had regenerated distally toward the target muscle was significantly higher in group 3 than that in groups 1 and 2. Immunohistochemistry validated the degree of connective tissue disruption among the 3 groups, and optical tissue clearing methods demonstrated donor axons traveling outside the fascicles in groups 1 and 2 but mostly within the fascicles in group 3. CONCLUSION Creating a perineurial window in the side of recipient nerves provides the best chances of robust donor axonal regeneration across the RETS repair site. This finding aids nerve surgeons by confirming that a deep window should be undertaken when doing a RETS procedure.
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Affiliation(s)
- Tak-Ho Chu
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Saud Alzahrani
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Amanda McConnachie
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Nicolas Lasaleta
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Amira Kalifa
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Rajesh Pathiyil
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
| | - Rajiv Midha
- Department of Clinical Neurosciences, University of Calgary, Calgary , Alberta , Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary , Alberta , Canada
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25
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Roubaud M, Asaad M, Liu J, Mericli A, Kapur S, Adelman D, Hanasono M. Free Fillet Flap of Lower Extremity: 38 Amputations with Seven Examples of Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces. Plast Reconstr Surg 2023; 152:883-895. [PMID: 36780349 DOI: 10.1097/prs.0000000000010294] [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] [Indexed: 02/14/2023]
Abstract
BACKGROUND Extremely high-level lower extremity amputations are rare procedures that require significant soft-tissue and bony reconstruction. This study describes the use of fillet flaps for oncologic reconstruction and the incorporation of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNIs) for chronic pain prevention. METHODS The authors performed a retrospective review of patients who underwent lower extremity fillet flaps at MD Anderson Cancer Center from January of 2004 through April of 2021. Surgical outcomes were summarized and compared. Numeric rating scale and patient-reported outcomes measures were collected. RESULTS Thirty-eight fillet flaps were performed for lower extremity reconstruction. Extirpative surgery included external hemipelvectomy (42%), external hemipelvectomy with sacrectomy (32%), and supratrochanteric above-knee amputation (26%). Median defect size was 600 cm 2 , and 50% included a bony component. Twenty-one patients (55%) experienced postoperative complications, with 16 requiring operative intervention. There was an increased trend toward complications in patients with preoperative radiotherapy, although this was not significant (44% versus 65%; P = 0.203). Seven patients underwent TMR or RPNI. In these patients, the mean numeric rating scale residual limb pain score was 2.8 ± 3.4 ( n = 5; range, 0 to 4/10) and phantom limb pain was 4 ± 3.2 ( n = 6; range, 0 to 7/10). The mean Patient-Reported Outcomes Measures Information Systems T scores were as follows: pain intensity, 50.8 ± 10.6 ( n = 6; range, 30.7 to 60.5); pain interference, 59.2 ± 12.1 ( n = 5; range, 40.7 to 70.1); and pain behavior, 62.3 ± 6.7 ( n = 3; range, 54.6 to 67.2). CONCLUSIONS Lower limb fillet flaps are reliable sources of bone, soft tissue, and nerve for reconstruction of oncologic amputation. TMR or RPNI are important new treatment adjuncts that should be considered during every amputation. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Margaret Roubaud
- From the Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center
| | - Malke Asaad
- Department of Plastic Surgery, University of Pittsburgh Medical Center
| | - Jun Liu
- From the Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center
| | - Alexander Mericli
- From the Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center
| | - Sahil Kapur
- From the Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center
| | - David Adelman
- From the Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center
| | - Matthew Hanasono
- From the Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center
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26
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Bendale G, Smith M, Daniel L, deBruler I, Fernandes Gragnani M, Clement R, McNeice J, Griffitts F, Sonntag M, Griffis J, Clements I, Isaacs J. In Vivo Efficacy of a Novel, Sutureless Coaptation Device for Repairing Peripheral Nerve Defects. Tissue Eng Part A 2023; 29:461-470. [PMID: 37114683 PMCID: PMC10517328 DOI: 10.1089/ten.tea.2023.0004] [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] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/26/2023] [Indexed: 04/29/2023] Open
Abstract
Although microsuture neurorrhaphy is the accepted clinical standard treatment for severed peripheral nerves, this technique requires microsurgical proficiency and still often fails to provide adequate nerve approximation for effective regeneration. Entubulation utilizing commercially available conduits may enhance the technical quality of the nerve coaptation and potentially provide a proregenerative microenvironment, but still requires precise suture placement. We developed a sutureless nerve coaptation device, Nerve Tape®, that utilizes Nitinol microhooks embedded within a porcine small intestinal submucosa backing. These tiny microhooks engage the outer epineurium of the nerve, while the backing wraps the coaptation to provide a stable, entubulated repair. In this study, we examine the impact of Nerve Tape on nerve tissue and axonal regeneration, compared with repairs performed with commercially available conduit-assisted or microsuture-only repairs. Eighteen male New Zealand white rabbits underwent a tibial nerve transection, immediately repaired with (1) Nerve Tape, (2) conduit plus anchoring sutures, or (3) four 9-0 nylon epineurial microsutures. At 16 weeks postinjury, the nerves were re-exposed to test sensory and motor nerve conduction, measure target muscle weight and girth, and perform nerve tissue histology. Nerve conduction velocities in the Nerve Tape group were significantly better than both the microsuture and conduit groups, while nerve compound action potential amplitudes in the Nerve Tape group were significantly better than the conduit group only. Gross morphology, muscle characteristics, and axon histomorphometry were not statistically different between the three repair groups. In the rabbit tibial nerve repair model, Nerve Tape offers similar regeneration efficacy compared with conduit-assisted and microsuture-only repairs, suggesting minimal impact of microhooks on nerve tissue.
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Affiliation(s)
- Geetanjali Bendale
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Matt Smith
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lida Daniel
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Isabelle deBruler
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | | | | | | | | | | | - Jonathan Isaacs
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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27
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Rasulić L. Trends, insights, and innovations in European peripheral nerve surgery. Neurol Res 2023; 45:874-875. [PMID: 37559232 DOI: 10.1080/01616412.2023.2184035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Lukas Rasulić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department for Peripheral Nerve Surgery, Functional Neurosurgery and Pain Management Surgery Clinic for Neurosurgery, Clinical Center of Serbia, Belgrade, Serbia
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Zhang M, An H, Gu Z, Huang Z, Zhang F, Jiang BG, Wen Y, Zhang P. Mimosa-Inspired Stimuli-Responsive Curling Bioadhesive Tape Promotes Peripheral Nerve Regeneration. Adv Mater 2023; 35:e2212015. [PMID: 37205796 DOI: 10.1002/adma.202212015] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/14/2023] [Indexed: 05/21/2023]
Abstract
Trauma often results in peripheral nerve injuries (PNIs). These injuries are particularly challenging therapeutically because of variable nerve diameters, slow axonal regeneration, infection of severed ends, fragility of the nerve tissue, and the intricacy of surgical intervention. Surgical suturing is likely to cause additional damage to peripheral nerves. Therefore, an ideal nerve scaffold should possess good biocompatibility, diameter adaptability, and a stable biological interface for seamless biointegration with tissues. Inspired by the curl of Mimosa pudica, this study aimed to design and develop a diameter-adaptable, suture-free, stimulated curling bioadhesive tape (SCT) hydrogel for repairing PNI. The hydrogel is fabricated from chitosan and acrylic acid-N-hydroxysuccinimide lipid via gradient crosslinking using glutaraldehyde. It closely matches the nerves of different individuals and regions, thereby providing a bionic scaffold for axonal regeneration. In addition, this hydrogel rapidly absorbs tissue fluid from the nerve surface achieving durable wet-interface adhesion. Furthermore, the chitosan-based SCT hydrogel loaded with insulin-like growth factor-I effectively promotes peripheral nerve regeneration with excellent bioactivity. This procedure for peripheral nerve injury repair using the SCT hydrogel is simple and reduces the difficulty and duration of surgery, thereby advancing adaptive biointerfaces and reliable materials for nerve repair.
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Affiliation(s)
- Meng Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, National Center for Trauma Medicine, Beijing, 100044, China
| | - Heng An
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Daxing Research Institute, School of Chemistry & Biological Engineering, University of Science and Technology Beijing, Beijing, 100083, China
| | - Zhen Gu
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Daxing Research Institute, School of Chemistry & Biological Engineering, University of Science and Technology Beijing, Beijing, 100083, China
| | - Zhe Huang
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Daxing Research Institute, School of Chemistry & Biological Engineering, University of Science and Technology Beijing, Beijing, 100083, China
| | - Fengshi Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, National Center for Trauma Medicine, Beijing, 100044, China
| | - Bao-Guo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, National Center for Trauma Medicine, Beijing, 100044, China
| | - Yongqiang Wen
- Beijing Key Laboratory for Bioengineering and Sensing Technology, Daxing Research Institute, School of Chemistry & Biological Engineering, University of Science and Technology Beijing, Beijing, 100083, China
| | - Peixun Zhang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Key Laboratory of Trauma and Neural Regeneration (Peking University), Ministry of Education, National Center for Trauma Medicine, Beijing, 100044, China
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29
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Walsh AR, Beutel BG, Tordjman D, da Costa AC, Melamed E. Neuroma-in-continuity: a review of pathophysiology and approach to the affected patient. Hand Surg Rehabil 2023; 42:103-108. [PMID: 36758942 DOI: 10.1016/j.hansur.2023.01.010] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
A neuroma-in-continuity is a neuroma resulting from a nerve injury in which internal neuronal elements are partially disrupted (with a variable degree of disruption to the endoneurium and perineurium) while the epineurium typically remains intact. The portion of injured axons are misdirected and embedded in connective tissue, which may give rise to local neuroma pain and a distal nerve deficit. The lesion may result from a multitude of injury mechanisms, and clinical presentation is often variable depending on the nerve affected. Clinical, electrodiagnostic, and imaging examinations are helpful in assessing the extent and degree of the lesion. If no clear evidence of recovery is identified within 3-4 months post-injury, the patient may benefit from operative exploration. Surgical management options include neurolysis, neuroma resection, nerve grafting, and nerve transfer, or a combination of modalities. A primary consideration of surgery is the possibility of further downgrading nerve function in the pursuit of more, thereby highlighting the need to carefully weigh the advantages and disadvantages prior to surgical intervention. The objective of this review article is to describe the current understanding of the pathophysiology of neuroma-in-continuity lesions, and to review the approach to the affected patient including clinical evaluation, ancillary testing, and intraoperative assessment and treatment options.
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Affiliation(s)
- Amanda R Walsh
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, New York, 11373, USA.
| | - Bryan G Beutel
- Kansas City University, 1750 Independence Avenue, Kansas City, Missouri, 64106, USA.
| | - Daniel Tordjman
- Hand Surgery Unit, Orthopedic Division, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, 6423906 Tel Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, P.O.B 39040, Ramat Aviv, Tel Aviv, Israel.
| | - Antonio Carlos da Costa
- Hand Surgery Division, Department of Orthopedics and Traumatology, Faculdade de Ciencias Medicas Santa Casa da Misericordia de São Paulo, R. Jaguaribe, 155 - Vila Buarque, São Paulo, Brazil.
| | - Eitan Melamed
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, 79-01 Broadway, Elmhurst, New York, 11373, USA.
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30
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Zelenski NA, Oishi T, Shin AY. Intraoperative Neuromonitoring for Peripheral Nerve Surgery. J Hand Surg Am 2023; 48:396-401. [PMID: 36623946 DOI: 10.1016/j.jhsa.2022.11.022] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/21/2022] [Accepted: 11/09/2022] [Indexed: 01/09/2023]
Abstract
Intraoperative neuromonitoring is a valuable surgical resource that can assist in decision-making during peripheral nerve surgery using real-time electrophysiologic data. By stimulating a nerve and recording action potentials from a point on the nerve ("nerve action potential") or from a muscle ("triggered electromyography"), nerve lesions can be localized and the extent of nerve damage evaluated. The purpose of this article is to provide an overview of the role, indications, and techniques of intraoperative neuromonitoring of peripheral nerve injuries.
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Abstract
BACKGROUND Acellular nerve allografts have been used successfully and with increasing frequency to reconstruct nerve injuries. As their use has been expanded to treat longer gap, larger diameter nerve injuries, some failed cases have been reported. We present the histomorphometry of 5 such cases illustrating these limitations and review the current literature of acellular nerve allografts. METHODS Between 2014 and 2019, 5 patients with iatrogenic nerve injuries to the median or ulnar nerve reconstructed with an AxoGen AVANCE nerve allograft at an outside hospital were treated in our center with allograft excision and alternative reconstruction. These patients had no clinical or electrophysiological evidence of recovery, and allograft specimens at the time of surgery were sent for histomorphological examination. RESULTS Three patients with a median and 2 with ulnar nerve injury were included. Histology demonstrated myelinated axons present in all proximal native nerve specimens. In 2 cases, axons failed to regenerate into the allograft and in 3 cases, axonal regeneration diminished or terminated within the allograft. CONCLUSIONS The reported cases demonstrate the importance of evaluating the length and the function of nerves undergoing acellular nerve allograft repair. In long length, large-diameter nerves, the use of acellular nerve allografts should be carefully considered.
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Affiliation(s)
- Blair R. Peters
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Oregon Health & Science Univeristy, Portland, OR, USA
| | - Matthew D. Wood
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A. Hunter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Howard SD, Aysola J, Montgomery CT, Kallan MJ, Xu C, Mansour M, Nguyen J, Ali ZS. Post-operative neurosurgery outcomes by race/ethnicity among enhanced recovery after surgery (ERAS) participants. Clin Neurol Neurosurg 2023; 224:107561. [PMID: 36549219 DOI: 10.1016/j.clineuro.2022.107561] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Prior work reveals that Enhanced Recovery After Surgery (ERAS) programs decrease opioid use, improve mobilization, and shorten length of stay (LOS) among patients undergoing spine surgery. The impact of ERAS on outcomes by race/ethnicity is unknown. This study examined outcomes by race/ethnicity among neurosurgical patients enrolled in an ERAS program. METHODS Patients undergoing elective spine or peripheral nerve surgeries at a multi-hospital university health system from April 2017 to November 2020 were enrolled in an ERAS program that involves preoperative, perioperative, and postoperative phases focused on improving outcomes through measures such as specialty consultations for co-morbidities, multimodal analgesia, early mobilization, and wound care education. The following outcomes for ERAS patients were compared by race/ethnicity: length of stay, discharge disposition, complications, readmission, pain level at discharge, and post-operative health rating. We estimated the association between race/ethnicity and the outcomes using linear and logistic regression models adjusting for age, sex, insurance, BMI, comorbid conditions, and surgery type. RESULTS Among participants (n = 3449), 2874 (83.3%) were White and 575 (16.7%) were Black, Indigenous, and people of color (BIPOC). BIPOC patients had significantly longer mean length of stay compared to White patients (3.8 vs. 3.4 days, p = 0.005) and were significantly more likely to be discharged to a rehab or subacute nursing facility compared to White patients (adjusted odds ratio (95% CI): 3.01 (2.26-4.01), p < 0.001). The complication rate did not significantly differ between BIPOC and White patients (13.7% vs. 15.5%, p = 0.29). BIPOC patients were not significantly more likely to be readmitted within 30 days compared to White patients in the adjusted model (adjusted odds ratio (95% CI): 1.30 (0.91-1.86), p = 0.15) CONCLUSION: BIPOC as compared to White ERAS participants in ERAS undergoing neurosurgical procedures had significantly longer hospital stays and were significantly less likely to be discharged home. ERAS protocols present an opportunity to provide consistent high quality post-operative care, however while there is evidence that it improves care in aggregate, our results suggest significant disparities in outcomes by patient race/ethnicity despite enrollment in ERAS. Future inquiry must identify contributors to these disparities in the recovery pathway.
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Affiliation(s)
- Susanna D Howard
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Jaya Aysola
- Penn Medicine Center for Health Equity Advancement, Office of Chief Medical Officer, University of Pennsylvania Health System and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Canada T Montgomery
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chang Xu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maikel Mansour
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica Nguyen
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Zarina S Ali
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
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Thomson SE, Ng NY, Riehle MO, Kingham PJ, Dahlin LB, Wiberg M, Hart AM. Bioengineered nerve conduits and wraps for peripheral nerve repair of the upper limb. Cochrane Database Syst Rev 2022; 12:CD012574. [PMID: 36477774 PMCID: PMC9728628 DOI: 10.1002/14651858.cd012574.pub2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Traumatic peripheral nerve injury is common and incurs significant cost to individuals and society. Healing following direct nerve repair or repair with autograft is slow and can be incomplete. Several bioengineered nerve wraps or devices have become available as an alternative to direct repair or autologous nerve graft. Nerve wraps attempt to reduce axonal escape across a direct repair site and nerve devices negate the need for a donor site defect, required by an autologous nerve graft. Comparative evidence to guide clinicians in their potential use is lacking. We collated existing evidence to guide the clinical application of currently available nerve wraps and conduits. OBJECTIVES To assess and compare the effects and complication rates of licensed bioengineered nerve conduits or wraps for surgical repair of traumatic peripheral nerve injuries of the upper limb. To compare effects and complications against the current gold surgical standard (direct repair or nerve autograft). SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was 26 January 2022. We searched online and, where not accessible, contacted societies' secretariats to review abstracts from the British Surgical Society of the Hand, International Federation of Surgical Societies of the Hand, Federation of European Surgical Societies of the Hand, and the American Society for Peripheral Nerve from October 2007 to October 2018. SELECTION CRITERIA We included parallel group randomised controlled trials (RCTs) and quasi-RCTs of nerve repair in the upper limb using a bioengineered wrap or conduit, with at least 12 months of follow-up. DATA COLLECTION AND ANALYSIS We used standard Cochrane procedures. Our primary outcomes were 1. muscle strength and 2. sensory recovery at 24 months or more. Our secondary outcomes were 3. British Medical Research Council (BMRC) grading, 4. integrated functional outcome (Rosén Model Instrument (RMI)), 5. touch threshold, 6. two-point discrimination, 7. cold intolerance, 8. impact on daily living measured using the Disability of Arm Shoulder and Hand Patient-Reported Outcome Measure (DASH-PROM), 9. sensory nerve action potential, 10. cost of the device, and 11. adverse events (any and specific serious adverse events (further surgery)). We used GRADE to assess the certainty of the evidence. MAIN RESULTS Five studies involving 213 participants and 257 nerve injuries reconstructed with wraps or conduits (129 participants) or standard repair (128 participants) met the inclusion criteria. Of those in the standard repair group, 119 nerve injuries were managed with direct epineurial repair, and nine autologous nerve grafts were performed. One study excluded the outcome data for the repair using an autologous nerve graft from their analysis, as it was the only autologous nerve graft in the study, so data were available for 127 standard repairs. There was variation in the functional outcome measures reported and the time postoperatively at which they were recorded. Mean sensory recovery, assessed with BMRC sensory grading (range S0 to S4, higher score considered better) was 0.03 points higher in the device group (range 0.43 lower to 0.49 higher; 1 RCT, 28 participants; very low-certainty evidence) than in the standard repair group (mean 2.75 points), which suggested little or no difference between the groups, but the evidence is very uncertain. There may be little or no difference at 24 months in mean touch thresholds between standard repair (0.81) and repair using devices, which was 0.01 higher but this evidence is also very uncertain (95% confidence interval (CI) 0.06 lower to 0.08 higher; 1 trial, 32 participants; very low-certainty evidence). Data were not available to assess BMRC motor grading at 24 months or more. Repair using bioengineered devices may not improve integrated functional outcome scores at 24 months more than standard techniques, as assessed by the Rosén Model Instrument (RMI; range 0 to 3, higher scores better); the CIs allow for both no important difference and a better outcome with standard repair (mean RMI 1.875), compared to the device group (0.17 lower, 95% CI 0.38 lower to 0.05 higher; P = 0.13; 2 trials, 60 participants; low-certainty evidence). Data from one study suggested that the five-year postoperative outcome of RMI may be slightly improved after repair using a device (mean difference (MD) 0.23, 95% CI 0.07 to 0.38; 1 trial, 28 participants; low-certainty evidence). No studies measured impact on daily living using DASH-PROM. The proportion of people with adverse events may be greater with nerve wraps or conduits than with standard techniques, but the evidence is very uncertain (risk ratio (RR) 7.15, 95% CI 1.74 to 29.42; 5 RCTs, 213 participants; very low-certainty evidence). This corresponds to 10 adverse events per 1000 people in the standard repair group and 68 per 1000 (95% CI 17 to 280) in the device group. The use of nerve repair devices may be associated with a greater need for revision surgery but this evidence is also very uncertain (12/129 device repairs required revision surgery (removal) versus 0/127 standard repairs; RR 7.61, 95% CI 1.48 to 39.02; 5 RCTs, 256 nerve repairs; very low-certainty evidence). AUTHORS' CONCLUSIONS Based on the available evidence, this review does not support use of currently available nerve repair devices over standard repair. There is significant heterogeneity in participants, injury pattern, repair timing, and outcome measures and their timing across studies of nerve repair using bioengineered devices, which make comparisons unreliable. Studies were generally small and at high or unclear risk of bias. These factors render the overall certainty of evidence for any outcome low or very low. The data reviewed here provide some evidence that more people may experience adverse events with use of currently available bioengineered devices than with standard repair techniques, and the need for revision surgery may also be greater. The evidence for sensory recovery is very uncertain and there are no data for muscle strength at 24 months (our primary outcome measures). We need further trials, adhering to a minimum standard of outcome reporting (with at least 12 months' follow-up, including integrated sensorimotor evaluation and patient-reported outcomes) to provide high-certainty evidence and facilitate more detailed analysis of effectiveness of emerging, increasingly sophisticated, bioengineered repair devices.
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Affiliation(s)
- Suzanne E Thomson
- Canniesburn Plastic Surgery Unit & Scottish National Brachial Plexus Injury Service, Glasgow Royal Infirmary, Glasgow, UK
- School of Molecular Biosciences, University of Glasgow, Glasgow, UK
| | - Nigel Yb Ng
- Aberdeen Royal Infirmary, University of Aberdeen, Aberdeen, UK
| | - Mathis O Riehle
- School of Molecular Biosciences, University of Glasgow, Glasgow, UK
| | - Paul J Kingham
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Umeå, Sweden
| | - Lars B Dahlin
- Department of Translational Medicine - Hand Surgery, Lund University, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
| | - Mikael Wiberg
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Umeå, Sweden
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Andrew M Hart
- Canniesburn Plastic Surgery Unit & Scottish National Brachial Plexus Injury Service, Glasgow Royal Infirmary, Glasgow, UK
- School of Molecular Biosciences, University of Glasgow, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Ismayilzade M, Ince B, Zuhour M, Oltulu P, Aygul R. The effect of a gap concept on peripheral nerve recovery in modified epineurial neurorrhaphy: An experimental study in rats. Microsurgery 2022; 42:703-713. [PMID: 35388916 DOI: 10.1002/micr.30890] [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: 11/03/2021] [Revised: 01/25/2022] [Accepted: 03/30/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Several factors such as surgical approach that only consider topographic anatomy; inadequate fascicular alignment, extraepineurial sprouting in the repair zone; contact of axons with the suture area are the disadvantages of epineurial neurorrhaphy. Accordingly, axonal mismatch, neuroma, and unfavorable nerve recovery become inevitable. Neurotropism is the theory clarifying appropriate matching of the nerve fibers independently without needing surgical approach. The studies comparing the primary nerve repair with the nerve defects bridged in different ways demonstrated better outcomes of nerve recovery in the groups with a nerve gap. In this study, we aimed to demonstrate the effects of the gap concept in primary nerve repair bridged by own epineurium. We hypothesized that this technique will provide better results in terms of peripheral nerve recovery and will significantly eliminate the occurrence of a neuroma, which is quite possible in epineurial neurorrhaphy. MATERIALS AND METHODS A total of 35 Wistar female rats weighing 200 ~ 250 g were randomly divided into five groups each with seven rats. Sham controls constituted Group 1, while the rats with epineural neurorrhaphy were included in Group 2. The remaining three groups were the study groups. In Group 3, after the sciatic nerve transection, epineurium of the distal segment was sleeved and preserved. A 2-mm axonal segment was removed from the epineurium free distal ending and no any procedure was applied to the proximal ending of the transected sciatic nerve. Epineuriums of the both sides were approximated and repaired. In Group 4, a 2-mm axonal segment was removed from the proximal ending of the sciatic nerve after preservation of epineurium and no any procedure was applied to the distal part of sciatic nerve. Epineuriums of the both sides were approximated and repaired. In addition, in Group 5, after epineuriums were sleeved in the both distal and proximal stumps, a 1-mm nerve segment was removed from both endings and epineuriums were repaired in the middle bridging a 2-mm axonal gap again. After a 3 months follow-up period Sciatic Functional Index (SFI) was measured by walking track analysis; the area under the evoked compound muscle action potential (CMAP) and latency periods were calculated via electromyographic (EMG) analysis; and histopathological evaluation were performed to compare the parameters of edema, fibrosis, inflammation, vascularization, axonal degeneration, axonal density, myelination, disorganization, and neuroma occurrence. Vascular structures and nerve fibers were counted at ×200 magnification: +1, +2, and +3 indicated the presence of 0-15, 16-30, and >30 structures, respectively. For uncountable parameters (edema, disorganization, myelination, fibrosis, and inflammation): +1 indicated mild, +2 indicated moderate, and +3 indicated severe. RESULTS The differences between the groups with axonal gap repair and epineural neurorrhaphy were not significant regarding to SFI. The areas under CMAP were as follows: 27.9 ± 5.9 (Δ = 12.1%) in Group 1; 16.5 ± 5.5 (Δ = 6.3%) in Group 2; 14.1 ± 6.2 (Δ = 4.8%) in group 3; 13.8 ± 2.3 (Δ = 9.2%) in Group 4, and 22.5 ± 18.3 (Δ = 2.2%) in Group 5. Group 5 (1 mm gap in the distal +1 mm gap in the proximal segments) had a significantly better result in terms of the area under CMAP with the value of 22.5 ± 18.3 m/Mv (p = .031). Axonal density was 0.9 ± 0.6 (Δ = 2.2%) in Group 2, 2.4 ± 0.3 (Δ = 5.1%) in Group 3, 2.8 ± 0.1 (Δ = 7.7%) in Group 4, and 2.8 ± 0.2 (Δ = 4.8%) in Group 5. Myelination was 1.1 ± 0.5 (Δ = 3.4%) in group 2, 2.2 ± 0.2 (Δ = 6.7%) in group 3, 2.4 ± 0.4 (Δ = 6.0%) in Group 4, and 2.7 ± 0.3 (Δ = 4.6%) in Group 5. Disorganization was 2.3 ± 0.4 (Δ = 4.1%) in Group 2, 1.2 ± 0.2 (Δ = 7.7%) in Group 3, 1.3 ± 0.2 (Δ = 6.5%) in Group 4, and 1 ± 0.3 (Δ = 5.9%) in Group 5. And, neuroma occurrence was found 2.2 ± 0.6 (Δ = 2.8%) in Group 2 and 0.3 ± 0.2 (Δ = 0.1%) in Group 4 while neuroma was not encountered in Group 3 and Group 5. Comparison between the epineurial neurorrhaphy group and the groups with axonal defect revealed the statistically significant results in the factors of axonal density (p = .001), myelination (p = .028), disorganization (p = .016) and neuroma (p = .001). CONCLUSIONS Creating axonal gap bridged by own epineurium showed favorable results comparing with epineurial neurorrhaphy. Resection of a 1 mm axonal segment from the proximal and distal stumps following the epineurial sleeve procedure and performing the epineurium- only repair can facilitate the nerve regeneration. The feasibility of the described technique has been demonstrated in a small rat model and must be further validated in larger animals before clinical testing.
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Affiliation(s)
- Majid Ismayilzade
- Department of Plastic & Reconstructive and Aesthetic Surgery, Istinye University Faculty of Medicine, Liv Hospital Vadiistanbul, Istanbul, Turkey
| | - Bilsev Ince
- Department of Plastic & Reconstructive and Aesthetic Surgery, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Moath Zuhour
- Department of Plastic & Reconstructive and Aesthetic Surgery, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Pembe Oltulu
- Department of Pathology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Recep Aygul
- Department of Neurology, Medical Faculty of Selcuk University, Konya, Turkey
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Gill B, Cheng DS, Buchanan P, Lee DW. Review of Interventional Treatments for Cluneal Neuropathy. Pain Physician 2022; 25:355-363. [PMID: 35901475] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The most common presentation of cluneal neuropathy is ipsilateral low back and gluteal pain. Cluneal neuralgia has been described historically in surgical contexts, with much of the description and treatment related to entrapment and decompression, respectively. Treatment options for addressing axial low back pain have evolved with advancements in the field of interventional pain medicine, though clinical results remain inconsistent. Recent attention has turned toward peripheral nerve stimulation. Nonsurgical interventions targeting the superior and medial cluneal nerve branches have been performed in cases of low back and buttock pain, but there is no known review of the resulting evidence to support these practices. OBJECTIVES In this manuscript we provide a robust exploration and analysis of the available literature regarding treatment options for cluneal neuropathy. We provide clinical manifestations and recommendations for future study direction. STUDY DESIGN Narrative review. METHODS This was a systematic, evidence-based narrative, performed after extensive review of the literature to identify all manuscripts associated with interventional treatment of the superior and medial cluneal nerves. RESULTS Eleven manuscripts fulfilled inclusion criteria. Interventional treatment of the superior and middle cluneal nerves includes blockade with corticosteroid, alcohol neurolysis, peripheral nerve stimulation, radiofrequency neurotomy, and surgical decompression. LIMITATIONS The supportive evidence for interventions in cluneal neuropathy is largely lacking due to small, uncontrolled, observational studies with multiple confounding factors. There is no standardized definition of cluneal neuropathy. CONCLUSION Limited studies promote beneficial effects from interventions intended to target cluneal neuropathy. Despite increased emphasis and treatment options for this condition, there is little consensus on the diagnostic criteria, endpoints, and measures of therapeutics, or procedural techniques for blocks, radiofrequency, and neuromodulation. It is imperative to delineate pathology associated with the cluneal nerves and perform rigorous analysis of associated treatment options.
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Affiliation(s)
- Benjamin Gill
- Department of Physical Medicine and Rehabilitation, University of Missouri, Columbia, Missouri
| | - David S Cheng
- Department of Neurological Surgery, University of Southern California, Los Angeles, California
| | - Patrick Buchanan
- Spanish Hills Interventional Pain Specialists, Camarillo, California
| | - David W Lee
- Fullerton Orthopedic Surgery Medical Group; Fullerton, California
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36
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Foy C, Olivella G, Kuffler D. Prospects for Improving the Extent of Recovery following Peripheral Nerve Trauma: A Review. P R Health Sci J 2022; 41:89-95. [PMID: 35704527] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Restoring function to damaged peripheral nerves with a gap remains challenging, with <50% of patients who undergo nerve repair surgery recovering function. Further, despite enormous efforts to improve existing techniques and develop new ones, the percentage of patients who recover function and their extent of recovery has not increased in almost 70 years. Thus, although sensory nerve grafts remain the clinical "gold standard" technique for attempting to restore function to nerves with a gap, they have significant limitations. They are effective in restoring good to excellent function only for gaps <3-5 cm, repairs performed <3-5 months post-trauma, and patients <20-25 years old. As the value of any of these variables increases, the extent of recovery decreases precipitously, and if the values of two or all three variables increase, there is little to no recovery. Therefore, novel techniques are required that increase the percentage of patients who recover function and the extent of their recovery. This review discusses the limitations of sensory nerve grafts and other techniques currently being used to repair nerves. It also discusses the use of autologous platelet-rich plasma (PRP), which appears to be the most promising technique for inducing sensory and motor recovery even when the values of all three variables are significantly greater than when sensory nerve grafts alone are not effective. Thus, there is finally the promise that patients who presently have limited to no chance of any recovery may recover good to excellent sensory and motor function.
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Affiliation(s)
- Christian Foy
- Section of Orthopedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Gerardo Olivella
- Section of Orthopedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Damien Kuffler
- Institute of Neurobiology, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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Zeiderman MR, Fine J, Asserson DB, Davé DR, Bascone CM, Li AI, Pereira CT. Sensorimotor Outcomes of Upper Extremity End-to-Side Nerve Transfers: A Meta-analysis. Ann Plast Surg 2022; 88:S337-S342. [PMID: 35180756 DOI: 10.1097/sap.0000000000003082] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND End-to-side nerve transfer (ETSNT) for treatment of peripheral nerve injuries is controversial given the myriad anatomic locations, injury types, and indications. Efficacy of ETSNT remains debated. We hypothesized differences in age, sex, transfer location, and time to surgery influence outcomes. METHODS We performed a search of the PubMed database for ETSNT in the upper extremity from 1988 to 2018. Age, sex, transfer location, time to surgery, donor and recipient axons, and strength and sensation outcomes as measured by Medical Research Council scale were extracted from articles. Meaningful recovery was classified as Medical Research Council Grade 3 or greater. Association between meaningful recovery and younger (<25) and older (≥25) patients, injury mechanism, sex, transfer location, donor axons, and recipient axons were calculated using a χ 2 or Fisher exact test. A logistic mixed effect model was used with time to surgery, age (categorical), transfer location, and injury type as a fixed effect, and a random paper effect was included to account for correlation among patients from the same paper. RESULTS One hundred fifteen patients from 11 studies were included. Neither age (continuous variable, P = 0.68) nor time to surgery ( P = 0.28) affected meaningful recovery. Injury mechanism, sex, and younger age (<25 vs ≥25 years) were not associated with meaningful recovery. Within the brachial plexus ETSNT demonstrated median M4 ± 1 postoperative strength, with trunks/cords as the primary axon donor ( P = 0.03). The musculocutaneous nerve demonstrated promising but variable results in 31 patients with median strength M3 ± 4. Digital nerves consistently demonstrated meaningful sensory recovery as both donor and recipient axons (15 of 15, 100%). Logistic regression analysis demonstrated that odds of meaningful recovery after ETSNT are significantly greater for transfers within the brachial plexus compared with the distal arm (odds ratio, 41.9; 95% CI, 1.1-1586.7, P = 0.04), but location does not significantly affect meaningful recovery ( P = 0.22). CONCLUSIONS Patients undergoing ETSNT for digital nerve injury demonstrated meaningful recovery. End-to-side nerve transfer seems to be more efficacious when performed within the brachial plexus. This study did not find sex, injury mechanism, or time to surgery to significantly affect meaningful recovery. Additional study is needed to better evaluate the effectiveness of ETSNT in the upper extremity.
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Affiliation(s)
- Matthew R Zeiderman
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California Davis, Davis
| | - Jeffrey Fine
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California Davis, Davis
| | | | - Dattesh R Davé
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California Davis, Davis
| | - Corey M Bascone
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California Davis, Davis
| | - Andrew I Li
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California Davis, Davis
| | - Clifford T Pereira
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California Davis, Davis
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Abstract
Electrophysiological monitoring of the peripheral nervous system during a variety of surgeries provides useful information that supplements and complements preoperative assessment. Monitoring improves localization and understanding of the underlying pathophysiology of peripheral nerve lesions leading to more rational treatment decisions and improved outcomes. Monitoring is accomplished by adaptation of routine electrodiagnostic techniques (i.e., nerve conduction studies, evoked potentials, and electromyography) with special attention to technical factors including electrical and movement artifact. These techniques have been successfully applied during surgery for entrapment neuropathies, traumatic nerve injury and repair, peripheral nerve tumors, and adjacent structure procedures that risk peripheral nerve injury. A clear understanding of the anatomy and neurophysiology is necessary, as is understanding and performing the difficult technical aspects of these studies to provide accurate information to enhance patient outcome and recovery. As in any intraoperative neurophysiologic monitoring (IONM) setting, constant and accurate communication between the IONM team, surgeon, and anesthesia team is critically important to meet these goals.
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Affiliation(s)
- Jeffrey A Strommen
- Department of Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States.
| | - Stanley Skinner
- Department of Intraoperative Neurophysiology, Abbott Northwestern Hospital, Minneapolis, MN, United States.
| | - Brian A Crum
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
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Lee MW, Jang N, Choi N, Yang S, Jeong J, Nam HS, Oh S, Kim K, Hwang D. In Vivo Cellular-Level 3D Imaging of Peripheral Nerves Using a Dual-Focusing Technique for Intra-Neural Interface Implantation. Adv Sci (Weinh) 2022; 9:e2102876. [PMID: 34845862 PMCID: PMC8787432 DOI: 10.1002/advs.202102876] [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] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/09/2021] [Indexed: 06/13/2023]
Abstract
In vivo volumetric imaging of the microstructural changes of peripheral nerves with an inserted electrode could be key for solving the chronic implantation failure of an intra-neural interface necessary to provide amputated patients with natural motion and sensation. Thus far, no imaging devices can provide a cellular-level three-dimensional (3D) structural images of a peripheral nerve in vivo. In this study, an optical coherence tomography-based peripheral nerve imaging platform that employs a newly proposed depth of focus extension technique is reported. A point spread function with the finest transverse resolution of 1.27 µm enables the cellular-level volumetric visualization of the metal wire and microstructural changes in a rat sciatic nerve with the metal wire inserted in vivo. Further, the feasibility of applying the imaging platform to large animals for a preclinical study is confirmed through in vivo rabbit sciatic nerve imaging. It is expected that new possibilities for the successful chronic implantation of an intra-neural interface will open up by providing the 3D microstructural changes of nerves around the inserted electrode.
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Affiliation(s)
- Min Woo Lee
- Center for Intelligent and Interactive RoboticsKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Namseon Jang
- Center for Intelligent and Interactive RoboticsKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Nara Choi
- Center for Intelligent and Interactive RoboticsKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Sungwook Yang
- Center for Intelligent and Interactive RoboticsKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Jinwoo Jeong
- Center for Intelligent and Interactive RoboticsKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Hyeong Soo Nam
- Department of Mechanical EngineeringKorea Advanced Institute of Science and TechnologyDaejeon34141Republic of Korea
| | - Sang‐Rok Oh
- Center for Intelligent and Interactive RoboticsKorea Institute of Science and TechnologySeoul02792Republic of Korea
| | - Keehoon Kim
- Department of Mechanical EngineeringPohang University of Science and TechnologyGyeongbuk37673Republic of Korea
| | - Donghyun Hwang
- Center for Intelligent and Interactive RoboticsKorea Institute of Science and TechnologySeoul02792Republic of Korea
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40
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Abstract
This review is intended to describe and actualize the basic knowledge of the three basic entities that affect the peripheral nerve system and can be treated by surgery: nerve trauma, chronic nerve compressions, and tumors.Regarding trauma, emphasis is given on the timing of surgery, given the fact that the moment in which the surgery is performed and the employed microsurgical reconstruction technique are the most important factors in the final result. Open lesions with associated nerve injury should be managed with an early exploration carried out before 7 days. Closed injuries are usually deferred, with few exceptions, from 3 to 6 months after the trauma.In turn, chronic compressions require an appropriate clinical, neurophysiological, and imaging diagnosis. Isolated sensory symptoms can be treated actively though without surgery: motor signs like atrophy should be regarded as a sign for immediate surgery, as a deferred treatment might cause an irreversible nerve and muscular damage. Endoscopic approaches are a valuable tool for treatment in selected neuropathies.Finally, nerve tumors demand a thorough preoperative evaluation, as benign tumors are treated in a very different way when compared to malignant lesions. Benign tumors can usually be safely and completely resected without sacrificing the nerve of origin. When malignancy is confirmed, extensive resection to optimize patient survival is the main objective, potentially at the expense of neurological function. This may then be followed by adjuvant radiation and/or chemotherapy, depending on the nature of the tumor and the completeness of resection attained. The role of nerve biopsy remains controversial, and several modern diagnostic techniques might be helpful.
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Affiliation(s)
| | - Carlos Rodríguez-Aceves
- Neurological Center, The American British Cowdray Medical Center campus Santa Fe, Mexico City, Mexico
| | - Fernando Martínez-Benia
- Department of Neurosurgery, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Mariano Socolovsky
- Department of Neurosurgery, Hospital de Clínicas, Universidad de Buenos Aires, Buenos Aires, Argentina.
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41
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Abstract
Background: Digital nerves will experience tension under normal daily activities, and understanding the amount of tension experienced in these nerves relates directly to the necessary strength in nerve repairs. To begin quantification of tension, the tension borne by the median and digital nerves in cadaveric hands was quantified under conditions of finger hyperextension, nerve distraction, and finger flexion. Methods: Five cadaveric hands were mounted in a special fixture that allowed finger hyperextension and flexion and could apply known distractions while the tension borne by each digital nerve was measured. Sequential dissection exposed the digital nerves so that measurements of tension in the median, common, and proper digital nerves were conducted with finger hyperextension, nerve distraction, and finger flexion. Results: Metacarpophalangeal (MCP) hyperextension of 30° created mean nerve tensions up to 0.64 N, 5 mm of nerve distraction created mean nerve tensions up to 1.23 N, and 90° of MCP flexion relieved up to a mean of 1.18 N of nerve tension. Conclusions: In situ tension is present in the median and digital nerves with digital motion. Finger hyperextension and nerve distraction produce tension, whereas finger flexion reduces tension. Existing nerve repairs are strong enough to withstand in situ nerve tensions produced by reasonable digital motion if the original nerve length is present.
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Affiliation(s)
| | - Patrick J. Schimoler
- Allegheny Health Network, Pittsburgh, PA, USA
- University of Pittsburgh, PA, USA
- Patrick J. Schimoler, Orthopaedic Biomechanics Laboratory, Department of Orthopaedic Surgery, Allegheny General Hospital, Allegheny Health Network, 10th Floor, South Tower, 320 East North Avenue, Pittsburgh, PA 15212, USA.
| | - Mark Carl Miller
- Allegheny Health Network, Pittsburgh, PA, USA
- University of Pittsburgh, PA, USA
| | - Peter Tang
- Allegheny Health Network, Pittsburgh, PA, USA
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Takahashi T. [What are the More Attractive Points in Spinal and Peripheral Nerve Surgery?]. No Shinkei Geka 2021; 49:1114-1123. [PMID: 34879332 DOI: 10.11477/mf.1436204499] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
In Japan, most neurosurgeons still focus on brain surgery. However, it is important for a neurosurgeon to acquire knowledge and experience in the fields of spinal cord and peripheral nerve surgeries to improve their diagnostic ability and surgical skills for patients with neurological disorders. The appeal and attractive points of spinal cord and peripheral nerve surgery include the depth of diagnosis and variety of treatment options that take into account the achievement goals according to a patient's requirement. The Neurospinal Society of Japan continues to make efforts to facilitate education and experience in spinal cord and peripheral nerve surgery for Japanese neurosurgeons. Our society believes that as more neurosurgeons in Japan develop concern and interest in this field, their social and international roles will expand further.
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Bellaire CP, Inglesby DC, Marayati NF, Warburton AJ, Melamed E. Trends in Peripheral Nerve Epidemiology and Reconstruction: A State Database Study of Direct Repairs, Grafts, and Conduits. Ann Plast Surg 2021; 87:179-186. [PMID: 33833178 DOI: 10.1097/sap.0000000000002823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Peripheral nerve injuries (PNIs) are most commonly treated with direct nerve repair procedures or nerve autografts. However, recent advancements in synthetic and vein conduits have led to their increased utilization. The present study quantifies the incidence of these procedures over time and geography and identifies differences in complication rates, illustrating the current epidemiologic climate regarding conduit use for PNI repair. METHODS A query was conducted using the State Ambulatory Surgery and Services Databases data from 2006 to 2011 in both Florida and California for patients undergoing nerve repair, nerve grafting, synthetic conduits, and vein conduits. Patient zip code data were analyzed to determine the geographic distribution of various types of repair. In addition, text-mining algorithms were used to identify trends in PNI-related publications. RESULTS In the 6-year period investigated, direct nerve repair was the most frequently used procedure for PNIs. However, the utilization of direct repairs declined significantly from 2006 to 2011. Synthetic and vein conduits demonstrated a significant increase over the same period. There were significantly higher rates of complications for autologous grafts (3.3%), vein conduits (3.5%), and synthetic conduits (2.4%), as compared with direct nerve repairs (1.4%). There was a nonsignificant difference in infection rates between these types of nerve repair. CONCLUSIONS From an epidemiologic perspective, both graft and synthetic conduit-based PNI repairs are increasing in prevalence both in clinical practice and in the academic literature. This will likely continue in the future with the development of advancements in biologic and synthetic nerve conduit PNI repair options.
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Affiliation(s)
- Christopher P Bellaire
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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44
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Abstract
With the development of newer techniques for symptomatic neuroma treatment, such as regenerative peripheral nerve interface and targeted muscle reinnervation, transposition and coverage techniques often have been referred to as "passive techniques." In spite of its negative connotation, these passive techniques yield positive results in a majority of patients treated. The experienced surgeon has more options than ever before in the prevention and management of problematic neuromas. Critical appraisal of the current literature reveals no single, optimal standard of care. Instead, surgeons have a plethora of useful techniques that can be implemented on a case-by-case basis to optimize outcomes.
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Affiliation(s)
- Brian W Starr
- Section of Plastic Surgery, University of Cincinnati Medical Center, 231 Albert Sabin Way, Mail Location: 0513, Cincinnati, OH 45229, USA.
| | - Kevin C Chung
- Section of Plastic Surgery, The University of Michigan Health System, 1500 East Medical Center Drive, 2130 Taubman Center, SPC 5340, Ann Arbor, MI 48109-5340, USA
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Huang L, Yang X, Deng L, Ying D, Lu A, Zhang L, Yu A, Duan B. Biocompatible Chitin Hydrogel Incorporated with PEDOT Nanoparticles for Peripheral Nerve Repair. ACS Appl Mater Interfaces 2021; 13:16106-16117. [PMID: 33787211 DOI: 10.1021/acsami.1c01904] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The nerve guidance conduit (NGC) is a promising clinical strategy for regenerating the critical-sized peripheral nerve injury. In this study, the polysaccharide chitin is used to fabricate the hydrogel film for inducing the impaired sciatic nerve regeneration through incorporating the conductive poly(3,4-ethylenedioxythiophene) nanoparticles (PEDOT NPs) and modifying with cell adhesive tetrapeptide Cys-Arg-Gly-Asp (CRGD) (ChT-PEDOT-p). The partial deacetylation process of chitin for exposing the amino groups is performed to (i) improve the electrostatic interaction between chitin and the negatively charged PEDOT for enhancing the composite hydrogel strength and (ii) offer the active sites for peptide modification. The as-prepared hydrogel remarkably promotes the in vitro RSC-96 cell adhesion and proliferation, as well as the Schwann cell activity-related gene S100, NF-200, and myelin basic protein (MBP) expression. Function of gastrocnemius muscle and thickness of myelinated axon in chitin/PEDOT groups are analogous to the autograft in 10 mm rat sciatic nerve defect. Immunofluorescence, immunohistochemistry, western blotting, and toluidine blue staining analyses on the regenerated sciatic nerve explain that the attachment and proliferation enhancement of Schwann cells and angiogenesis are the vital factors for the chitin/PEDOT composite to facilitate the nerve regeneration. This work provides an applicable chitin-based NGC material for accelerating the peripheral nerve restoration.
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Affiliation(s)
- Lin Huang
- College of Chemistry and Molecular Sciences, Hubei Engineering Center of Natural Polymer-based Medical Materials, and Key Laboratory of Biomedical Polymers of Ministry of Education, Wuhan University, Wuhan 430072, China
| | - Xiaqing Yang
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Linglong Deng
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Daofa Ying
- College of Chemistry and Molecular Sciences, Hubei Engineering Center of Natural Polymer-based Medical Materials, and Key Laboratory of Biomedical Polymers of Ministry of Education, Wuhan University, Wuhan 430072, China
| | - Ang Lu
- College of Chemistry and Molecular Sciences, Hubei Engineering Center of Natural Polymer-based Medical Materials, and Key Laboratory of Biomedical Polymers of Ministry of Education, Wuhan University, Wuhan 430072, China
| | - Lina Zhang
- College of Chemistry and Molecular Sciences, Hubei Engineering Center of Natural Polymer-based Medical Materials, and Key Laboratory of Biomedical Polymers of Ministry of Education, Wuhan University, Wuhan 430072, China
| | - Aixi Yu
- Department of Orthopedics Trauma and Microsurgery, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China
| | - Bo Duan
- College of Chemistry and Molecular Sciences, Hubei Engineering Center of Natural Polymer-based Medical Materials, and Key Laboratory of Biomedical Polymers of Ministry of Education, Wuhan University, Wuhan 430072, China
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Bookman J, Hacquebord J. Peripheral Nerve Injuries in the Upper Extremity. Bull Hosp Jt Dis (2013) 2021; 79:11-16. [PMID: 33704032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Major peripheral nerve injuries are devastating and represent a very challenging clinical problem. Despite many years of advancement in peripheral nerve research, results so far have been fair at best, with only 50% of patients regaining useful function. Advancement of techniques in imaging, better understanding of the physiology of nerve recovery, improved repair and grafting options, and secondary reconstructive techniques, including tendon and nerve transfers, have helped facilitate a degree of more effective treatment. This article presents current concepts regarding the principles of management, expected outcomes, and new advancements in major upper extremity peripheral nerve injuries.
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Tsymbaliuk VI, Strafun SS, Tretyak IB, Tsymbaliuk IV, Gatskiy AA, Tsymbaliuk YV, Tatarchuk MM. SURGICAL TREATMENT OF PERIPHERAL NERVES COMBAT WOUNDS OF THE EXTREMITIES. Wiad Lek 2021; 74:619-624. [PMID: 33843623] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The aim: Improving the effectiveness of patients' treatment with combat injuries of the peripheral nervous system, which consists in the application and development of new methods of reconstructive interventions, optimizing a set of therapeutic and diagnostic measures for the most effective management of this category of patients with peripheral nerve injury. PATIENTS AND METHODS Materials and methods: The research is based on the results of surgical treatment of 138 patients with combat injuries of peripheral nerves for the period from 2014 to 2020. The mean age was 33.5 ± 2.1 years. Patients were treated for 1 to 11 months after injury (median - 8 months). Damage to the sciatic nerve was observed in 26.1%, ulnar - in 20.3%, median - in 18.8%, radial - in 15.9%, tibial - in 10.9%, common peroneal nerve - in 8% of cases. RESULTS Results: It was shown that in all patients was significantly improved the recovery of all nerves. In the period from 9 to 12 months, the degree of recovery of motor function to M0-M2 was observed in 40.6%, to M3 - in 35.5%, to M4 - in 16.7%, to M5 - in 7,2%. The degree of recovery of sensitivity to S0-S2 was observed in 36.2%, to S3 - in 42.8%, to S4 - in 17.4%, to S5 - in 3.6%. Regression of pain syndrome after surgery was observed in 81.2% of patients. CONCLUSION Conclusions: The results of surgical treatment of peripheral nerves gunshot injury are generally worse than other types of nerve injuries. The best results of surgical treatment of combat trauma of peripheral nerves are obtained in patients with sciatic nerve damage.
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Affiliation(s)
- Vitalii I Tsymbaliuk
- STATE INSTITUTION "ROMODANOV NEUROSURGERY INSTITUTE OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE", KYIV, UKRAINE
| | - Sergii S Strafun
- STATE INSTITUTION "THE INSTITUTE OF TRAUMATOLOGY AND ORTHOPEDICS BY THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE", KYIV, UKRAINE
| | - Ihor B Tretyak
- STATE INSTITUTION "ROMODANOV NEUROSURGERY INSTITUTE OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE", KYIV, UKRAINE
| | - Iaroslav V Tsymbaliuk
- STATE INSTITUTION "ROMODANOV NEUROSURGERY INSTITUTE OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE", KYIV, UKRAINE
| | - Alexander A Gatskiy
- STATE INSTITUTION "ROMODANOV NEUROSURGERY INSTITUTE OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE", KYIV, UKRAINE
| | - Yuliia V Tsymbaliuk
- STATE INSTITUTION "ROMODANOV NEUROSURGERY INSTITUTE OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE", KYIV, UKRAINE
| | - Mykhailo M Tatarchuk
- STATE INSTITUTION "ROMODANOV NEUROSURGERY INSTITUTE OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE", KYIV, UKRAINE
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Abstract
The application of advanced imaging guidance and the interventional radiology skill set has expanded the breadth of nerve and nerve plexus targets in the body for potential cryoneurolysis. Advancement of the basic science supporting cryoneurolysis has further solidified proceduralists' confidence and ability to select and manage patients clinically. As these procedures continue to evolve, a structured approach to the wide variety of indications is necessary.
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Affiliation(s)
- J David Prologo
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Faramarz Edalat
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA
| | - Mohamad Moussa
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA
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Park MR, Kim D, Rhyu IJ, Yu JH, Hong J, Yoon S, Lee D, Koh JC. An anatomical neurovascular study for procedures targeting peri-articular nerves in patients with anterior knee pain. Knee 2020; 27:1577-1584. [PMID: 33010776 DOI: 10.1016/j.knee.2020.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/29/2020] [Accepted: 08/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Radiofrequency ablation (RFA) of the articular branches innervating the anterior knee capsule has been studied as a possible alternative to surgery for degenerative arthritis. However, the neurovascular topography of the anterior knee capsule remains unclear. METHODS One leg from each of the 20 formalin-embalmed cadaveric specimens was investigated. Modified ablation points (MAPs) were evaluated for a possible alternative for conventional target points (CAPs). RESULTS For the nerve to vastus medialis (NVM), the probability of identifying the nerve was higher at MAP compared with CAP (62.5% vs. 25%). The mean shortest distance from the nerve was shorter at MAP compared with CAP (18.0 mm vs. 29.9 mm). The probabilities and distances for other nerves were not significantly different between the points. However, the probability of identifying the artery was significantly lower at MAPs compared with CAPs for arteries (0%, 5.3%, and 0% vs. 84.2%, 84.2%, and 73.3% for superior medial genicular, superior lateral genicular, and inferior medial genicular artery, respectively). For the recurrent peroneal nerve (RPN), a new target point was set in MAPs. CONCLUSIONS The current landmark for genicular nerve procedures may not accurately target the correct nerve position, or reduce the risk for vessel damage. A more proximal target may reduce complications and increase the probability of successful procedures, although clinical correlation is needed.
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Affiliation(s)
- Mi Ran Park
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Dasom Kim
- Department of Anatomy, Korea University College of Medicine, Seoul, Republic of Korea
| | - Im Joo Rhyu
- Department of Anatomy, Korea University College of Medicine, Seoul, Republic of Korea
| | - Joon Ho Yu
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jisu Hong
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Siyeop Yoon
- Center for Medical Robotics, Korea Institute of Science and Technology, Seoul, Republic of Korea
| | - Deukhee Lee
- Center for Medical Robotics, Korea Institute of Science and Technology, Seoul, Republic of Korea
| | - Jae Chul Koh
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, Republic of Korea.
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Otchy TM, Michas C, Lee B, Gopalan K, Nerurkar V, Gleick J, Semu D, Darkwa L, Holinski BJ, Chew DJ, White AE, Gardner TJ. Printable microscale interfaces for long-term peripheral nerve mapping and precision control. Nat Commun 2020; 11:4191. [PMID: 32826892 PMCID: PMC7442820 DOI: 10.1038/s41467-020-18032-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 07/29/2020] [Indexed: 12/28/2022] Open
Abstract
The nascent field of bioelectronic medicine seeks to decode and modulate peripheral nervous system signals to obtain therapeutic control of targeted end organs and effectors. Current approaches rely heavily on electrode-based devices, but size scalability, material and microfabrication challenges, limited surgical accessibility, and the biomechanically dynamic implantation environment are significant impediments to developing and deploying peripheral interfacing technologies. Here, we present a microscale implantable device - the nanoclip - for chronic interfacing with fine peripheral nerves in small animal models that begins to meet these constraints. We demonstrate the capability to make stable, high signal-to-noise ratio recordings of behaviorally-linked nerve activity over multi-week timescales. In addition, we show that multi-channel, current-steering-based stimulation within the confines of the small device can achieve multi-dimensional control of a small nerve. These results highlight the potential of new microscale design and fabrication techniques for realizing viable devices for long-term peripheral interfacing.
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Affiliation(s)
- Timothy M Otchy
- Department of Biology, Boston University, Boston, MA, 02215, USA.
- Neurophotonics Center, Boston University, Boston, MA, 02215, USA.
- Center for Systems Neuroscience, Boston University, Boston, MA, 02215, USA.
| | - Christos Michas
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA
| | - Blaire Lee
- Department of Biology, Boston University, Boston, MA, 02215, USA
| | - Krithi Gopalan
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA
| | - Vidisha Nerurkar
- Department of Biology, Boston University, Boston, MA, 02215, USA
| | - Jeremy Gleick
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA
| | - Dawit Semu
- Department of Biology, Boston University, Boston, MA, 02215, USA
| | - Louis Darkwa
- Department of Biology, Boston University, Boston, MA, 02215, USA
| | - Bradley J Holinski
- Bioelectronics Division, GlaxoSmithKline, Stevenage, Hertfordshire, SG1 2NY, UK
| | - Daniel J Chew
- Bioelectronics Division, GlaxoSmithKline, Stevenage, Hertfordshire, SG1 2NY, UK
| | - Alice E White
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA
- Department of Mechanical Engineering, Boston University, Boston, MA, 02215, USA
| | - Timothy J Gardner
- Department of Biology, Boston University, Boston, MA, 02215, USA.
- Neurophotonics Center, Boston University, Boston, MA, 02215, USA.
- Center for Systems Neuroscience, Boston University, Boston, MA, 02215, USA.
- Department of Biomedical Engineering, Boston University, Boston, MA, 02215, USA.
- Knight Campus, University of Oregon, Eugene, OR, 97405, USA.
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