Improved white matter integrity after contralateral seventh cervical nerve transfer measured by tractographic representation.

Contralateral C7 (CC7) nerve transfer surgery was shown to significantly improve the spasticity condition and the motor function of paralyzed arms. However, the involvement of the white matter tract in the recovery process is not well established. We here investigated the possible biologic explanation for this phenomenon. A 62-year-old female patient, who suffered from spastic hemiparesis due to intracranial hemorrhage, underwent CC7 transfer surgery 13 years after the initial stroke event. Six months after the surgery, the patient's Modified Ashworth Scale and Fugl-Myere score improved, even though no specific rehabilitation programs were applied. Diffusion tensor imaging (DTI) was performed before and 6 months after the surgery. The pre-surgery DTI showed both ipsilesional and contralesional CST from the cerebral peduncles to the cortices. After surgery, however, only the contralesional CST was observed. In conclusion, functional alterations of the brain white matter tract after CC7 nerve transfer surgery possibly provided a neurophysiological substrate for ameliorating the spasticity and improving the motor function in a spastic hemiplegia patient.

Clinical Anatomy of Human Donor C7 Nerve Roots for Surgical Transfer in Patients with Spastic Arm Paralysis.

BACKGROUND: Contralateral C7 (CC7) nerve transfer has successfully restored hand function in patients with spastic hemiplegia from chronic central nervous system injuries. However, little is known about the morphology and anatomy of the donor C7 nerve root in patients undergoing this procedure. This study quantified intraoperative measurements of donor C7 nerve roots during CC7 transfer surgery for spastic hemiplegia in patients treated at a high-volume center to describe observed anatomical variations for successful direct anastomosis. METHODS: A database of images from 21 patients (2 females, 19 males) undergoing CC7 surgery was searched for photographic data that contained a standard ruler measuring donor C7 nerve root length after surgical sectioning and before transfer. Two independent observers analyzed these images and recorded C7 nerve root diameter, length, and branch lengths. RESULTS: Mean (SD) values of donor C7 nerve measurements were length, 53.5 (8.0) mm; diameter, 5.1 (0.9) mm; branch length following surgical sectioning, 18.3 (6.3) mm. Right-sided donor C7 nerve roots yielded significantly longer branches compared with left-sided donor C7 nerve roots (P = 0.01). Other patient factors such as age, sex, or laterality of brain injury did not influence intraoperative anatomy. CONCLUSIONS: We report detailed intraoperative measurements of the donor C7 root during CC7 nerve transfer for spastic hemiplegia. These findings describe existing variation in surgical C7 nerve root anatomy in patients undergoing this procedure and may serve as a general reference for the expected donor C7 length in successful direct anastomosis.

Comparison of neuropathic pain characteristics associated with total brachial plexus injury before and after surgical repair: A retrospective study.

OBJECTIVES: The goal of this study was to compare clinical characteristics of neuropathic pain associated with total brachial plexus injury before and after surgeries and to correlate possible contributing factors concerning to the pain prognosis. PATIENTS AND METHODS: Thirty patients with both total brachial plexus injury and neuropathic pain were included. Neuropathic pain was evaluated in terms of pain intensities, symptoms and regions. Pain intensities were evaluated by a visual analogue scale. The Neuropathic Pain Symptoms Inventory questionnaire and body maps were used to compare the pain symptoms and regions. Demographic data, injury and repair information were evaluated to analyze the possible factors influencing the prognosis. RESULTS: The average pain score of all participants was 7.13 ± 2.46 preoperatively and 5.40 ± 2.08 postoperatively. All patients were divided into Pain Relief Group and Pain Aggravation Group. Older age (p = 0.042), machine traction injury (p = 0.019)and nerve transplantation(p = 0.015) seemed to be related with pain aggravation. Paroxysmal pain was aggravated after surgical repairs (p = 0.041), while paresthesia/dysesthesia improved after surgery (p = 0.003). The permanent component of the pain (spontaneous pain) did not show any significant change (p = 0.584). Pain in C5 (p < 0.001) and C6 (p = 0.031) dermatomes got relieved after surgery. CONCLUSION: This study revealed the neuropathic pain of most patients with total brachial plexus injury was alleviated after neurosurgery, and the pain prognosis of different symptoms and regions varied after the nerve repair.

Contralateral C7 transfers: An innovative approach to improving peripheral neuropathic pain after traumatic brachial plexus injury with C5 rupture and avulsion of C6, C7, C8 and T1. A case series study.

OBJECTIVES: Peripheral neuropathic pain is a common and disabling problem after traumatic brachial plexus injury with global plexopathy secondary to C5 rupture and avulsion of C6, C7, C8, and T1. The purpose of this paper is to evaluate restoration of sensation and pain levels before and after targeted muscle reinnervation to the hand using contralateral C7 nerve transfers in patients who have traumatic brachial plexus injuries with C5 rupture and avulsion of C6, C7, C8, and T1. PATIENTS AND METHODS: This paper presents a retrospective review of the outcomes of the surgical management of 11 patients with global plexopathy with C5 rupture and avulsion from C6 to T1 roots. Ten of the patients had peripheral neuropathic pain. Mean follow-up was 6.9 years. RESULTS: Sensory recovery to the median nerve territory was returned in 10 out of 11 patients. Pain and quality of life were improved in the majority. CONCLUSION: Contralateral C7 nerve transfers may restore sensation to the median nerve territory with concurrent improvement in pain and some function in a limited number of patients for whom no other treatment options exist.

Bladder reinnervation by somatic nerve transfer to pelvic nerve vesical branches does not reinnervate the urethra.

AIMS: We sought to determine whether somatic lumbar nerve transfer to the pelvic nerve's anterior vesical branch after sacral decentralization for detrusor muscle reinnervation also leads to aberrant innervation of the bladder outlet. METHODS: Twenty-six female mongrel hound dogs underwent transection of sacral dorsal and ventral spinal roots (ie, sacral decentralization). Immediately afterward, 12 received genitofemoral nerve transfer and 9 received femoral nerve branch transfer. Five were left sacrally decentralized. Controls included 3 sham-operated and 6 unoperated. Eight months postsurgery, the bladder and urethra were injected with retrograde tracing dyes cystoscopically. After 3 weeks, detrusor and urethral pressures were assayed electrophysiologically immediately before euthanasia and characterization of neural reinnervation. RESULTS: Electrical stimulation of spinal cords or roots did not lead to increased urethral sphincter pressure in nerve transfer animals, compared with decentralized animals, confirming a lack of functional reinnervation of the bladder outlet. In contrast, mean detrusor pressure increased after lumbar cord/root stimulation. In sham/unoperated animals, urethral and bladder dye injections resulted in labeled neurons in sacral level neural structures (dorsal root ganglia [DRG], sympathetic trunk ganglia [STG], and spinal cord ventral horns); labeling absent in decentralized animals. Urethral dye injections did not result in labeling in lumbar or sacral level neural structures in either nerve transfer group while bladder dye injections lead to increased labeled neurons in lumbar level DRG, STG, and ventral horns, compared to sacrally decentralized animals. CONCLUSION: Pelvic nerve transfer for bladder reinnervation does not impact urethral sphincter innervation.

Reconstruction of the Suprascapular Nerve in Brachial Plexus Birth Injury: A Comparison of Nerve Grafting and Nerve Transfers.

BACKGROUND: Shoulder external rotation recovery in brachial plexus birth injury is often limited. Nerve grafting to the suprascapular nerve and transfer of the spinal accessory nerve to the suprascapular nerve are commonly performed to restore shoulder external rotation, but the optimal surgical technique has not been clearly demonstrated. We investigated whether there was a difference between nerve grafting and nerve transfer in terms of shoulder external rotation recovery or secondary shoulder procedures. METHODS: This is a multicenter, retrospective cohort study of 145 infants with brachial plexus birth injury who underwent reconstruction with nerve grafting to the suprascapular nerve (n = 59) or spinal accessory nerve to suprascapular nerve transfer (n = 86) with a minimum follow-up of 18 months (median, 25.7 months [interquartile range, 22.0, 31.2 months]). The primary outcome was the Active Movement Scale (AMS) score for shoulder external rotation at 18 to 36 months. The secondary outcome was secondary shoulder surgery. Two-sample Wilcoxon and t tests were used to analyze continuous variables, and the Fisher exact test was used to analyze categorical variables. The Kaplan-Meier method was used to estimate the cumulative risk of subsequent shoulder procedures, and the proportional hazards model was used to estimate hazard ratios (HRs). RESULTS: The grafting and transfer groups were similar in Narakas type, preoperative AMS scores, and shoulder subluxation. The mean postoperative shoulder external rotation AMS scores were 2.70 in the grafting group and 3.21 in the transfer group, with no difference in shoulder external rotation recovery between the groups (difference, 0.51 [95% confidence interval (CI), -0.31 to 1.33]). A greater proportion of the transfer group (24%) achieved an AMS score of >5 for shoulder external rotation compared with the grafting group (5%) (odds ratio, 5.9 [95% CI, 1.3 to 27.4]). Forty percent of the transfer group underwent a secondary shoulder surgical procedure compared with 53% of the grafting group; this was a significantly lower subsequent surgery rate (HR, 0.58 [95% CI, 0.35 to 0.95]). CONCLUSIONS: Shoulder external rotation recovery in brachial plexus birth injury remains disappointing regardless of surgical technique, with a mean postoperative AMS score of 3, 17% of infants achieving an AMS score of >5, and a high frequency of secondary shoulder procedures in this study. Spinal accessory nerve to suprascapular nerve transfers were associated with a higher proportion of infants achieving functional shoulder external rotation (AMS score of >5) and fewer secondary shoulder procedures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Berberine enhances survival and axonal regeneration of motoneurons following spinal root avulsion and re-implantation in rats.

Brachial plexus avulsion (BPA) occurs when the spinal nerve roots are pulled away from the surface of the spinal cord and disconnects neuronal cell body from its distal downstream axon, which induces massive motoneuron death, motor axon degeneration and de-innervation of targeted muscles, thereby resulting in permanent paralysis of motor functions in the upper limb. Avulsion injury triggers oxidative stress and intense local neuroinflammation at the lesioned site, leading to the death of most motoneurons. Berberine (BBR), a natural isoquinoline alkaloid derived from medicinal herbs of Berberis and Coptis species, has been reported to possess neuro-protective, anti-inflammatory and anti-oxidative effects in various animal models of central nervous system (CNS)-related disorders. In this study, we aimed to investigate the effect of BBR on motoneuron survival and axonal regeneration following spinal root avulsion plus re-implantation in rats. Our results indicated BBR significantly accelerated motor function recovery in the forelimb as revealed by the increased Terzis grooming test score, facilitated motor axon regeneration as evidenced by the elevated number of Fluoro-Gold-labeled and P75-positive regenerative motoneurons. The survival of motoneurons was notably promoted by BBR administration presented with boosted ChAT-immunopositive and neutral red-stained neurons. BBR treatment efficiently alleviated muscle atrophy, attenuated functional motor endplates loss in biceps and prevented the reduction of motor axons in the musculocutaneous nerve. Additionally, BBR treatment markedly mitigated the avulsion-induced neuroinflammation via inhibiting microglial and astroglial reactivity, up-regulated the expression of antioxidative indicator Cu/Zn SOD, and down-regulated the levels of nNOS, 3-NT, lipid peroxidation and NF-κB, as well as promoted SIRT1, PI3K and Akt activation. Collectively, BBR might be a promising therapy to assist re-implantation surgery for the treatment of BPA.

Contralateral Lumbar to Sacral Nerve Rerouting for Hemiplegic Patients After Stroke: A Clinical Pilot Study.

BACKGROUND: Spasticity and muscle weakness are common severe neurologic sequelae after stroke. Contralateral peripheral neurotization has been applied successfully to promote motor function of the hemiplegic upper extremity in patients with central neurological injury. To our knowledge, we present the first report of contralateral lumbar to sacral nerve transfer for the lower extremities in hemiplegic patients after stroke. CASE DESCRIPTION: Two patients were enrolled in the study. The first patient is a 57-year-old man who experienced permanent muscle weakness in his left leg after a right cerebral infarction. The second patient is a 42-year-old man who had spasticity and hemiplegia in both upper and lower limbs on the right side 32 months after a left cerebral hemorrhage. Both patients underwent contralateral lumbar-to-sacral nerve rerouting to improve lower-limb motor function. Twenty months after surgery, both patients experienced significant improvement in ambulatory status. CONCLUSIONS: Although long-term follow-up and a randomized controlled trial are required, this study demonstrates the safety and possible benefits of contralateral lumbar-to-sacral nerve transfer for hemiplegic patients after stroke. This novel surgical approach could provide a new means for lower-limb motor functional recovery.

Pretreatment of nerve grafts with resveratrol improves axonal regeneration following replantation surgery for nerve root avulsion injury in rats.

BACKGROUND: Replantation of the avulsed nerve root has been proposed for the treatment of severe brachial plexus injury for several decades. However, due to the complexity of the technique and limited functional improvement, practical applications are yet to be implemented. OBJECTIVE: In the present study, we investigated the effect of pretreatment with resveratrol on nerve autografts used for replantation surgery in a rat model of nerve root avulsion. METHODS: Resveratrol pretreatment was performed using an explant culture technique. Two surgical procedures were performed. During the first surgery, Sprague-Dawley rats were subjected to left C6 nerve root avulsion, and nerves were harvested for autografting. The harvested grafts were explant-cultured for 1 week. A second procedure was performed to replant the C6 nerve root using the explant-cultured nerve graft 1 week after the first procedure. Histological and immunohistochemical analyses were performed 8 weeks after the second procedure. We first compared findings between explant-cultured nerve grafts and fresh nerve grafts, following which we compared findings between explant-cultured grafts pretreated with and without resveratrol. Changes induced within nerve grafts by 1 week of explant culture with or without resveratrol were investigated in vitro. RESULTS: There was no significant difference in outcomes between 1 week-explant-cultured and fresh nerve grafts. Addition of resveratrol to the explant culture medium resulted in a significant increase in the number and myelin thickness of regenerated axons, and in the number of regenerating motor neurons in the C6 spinal cord segment. In vitro analyses revealed that nerve grafts pretreated with resveratrol exhibited significant increases in glial cell line-derived neurotrophic factor (GDNF) expression and the number of dedifferentiated Schwann cells. CONCLUSIONS: Resveratrol may promote axonal regeneration following replantation surgery for the treatment of nerve root avulsion injury; however, further studies are required to verify these findings in humans.

Nerve fascicle transfer using a part of the C-7 nerve for spinal accessory nerve injury.

OBJECTIVE Spinal accessory nerve (SAN) injury results in a series of shoulder dysfunctions and continuous pain. However, current treatments are limited by the lack of donor nerves as well as by undesirable nerve regeneration. Here, the authors report a modified nerve transfer technique in which they employ a nerve fascicle from the posterior division (PD) of the ipsilateral C-7 nerve to repair SAN injury. The technique, first performed in cadavers, was then undertaken in 2 patients. METHODS Six fresh cadavers (12 sides of the SAN and ipsilateral C-7) were studied to observe the anatomical relationship between the SAN and C-7 nerve. The length from artificial bifurcation of the middle trunk to the point of the posterior cord formation in the PD (namely, donor nerve fascicle) and the linear distance from the cut end of the donor fascicle to both sites of the jugular foramen and medial border of the trapezius muscle (d-SCM and d-Traps, respectively) were measured. Meanwhile, an optimal route for nerve fascicle transfer (NFT) was designed. The authors then performed successful NFT operations in 2 patients, one with an injury at the proximal SAN and another with an injury at the distal SAN. RESULTS The mean lengths of the cadaver donor nerve fascicle, d-SCM, and d-Traps were 4.2, 5.2, and 2.5 cm, respectively. In one patient who underwent proximal SAN excision necessitated by a partial thyroidectomy, early signs of reinnervation were seen on electrophysiological testing at 6 months after surgery, and an impaired left trapezius muscle, which was completely atrophic preoperatively, had visible signs of improvement (from grade M0 to grade M3 strength). In the other patient in whom a distal SAN injury was the result of a neck cyst resection, reinnervation and complex repetitive discharges were seen 1 year after surgery. Additionally, the patient's denervated trapezius muscle was completely resolved (from grade M2 to grade M4 strength), and her shoulder pain had disappeared by the time of final assessment. CONCLUSIONS NFT using a partial C-7 nerve is a feasible and efficacious method to repair an injured SAN, which provides an alternative option for treatment of SAN injury.

Functional connectivity of motor cortical network in patients with brachial plexus avulsion injury after contralateral cervical nerve transfer: a resting-state fMRI study.

INTRODUCTION: The purpose of this study is to assess the functional connectivity of the motor cortical network in patients with brachial plexus avulsion injury (BPAI) after contralateral C7 nerve transfer, using resting-state functional magnetic resonance imaging (RS-fMRI). METHODS: Twelve patients with total brachial plexus root avulsion underwent RS-fMRI after contralateral C7 nerve transfer. Seventeen healthy volunteers were also included in this fMRI study as controls. The hand motor seed regions were defined as region of interests in the bilateral hemispheres. The seed-based functional connectivity was calculated in all the subjects. Differences in functional connectivity of the motor cortical network between patients and healthy controls were compared. RESULTS: The inter-hemispheric functional connectivity of the M1 areas was increased in patients with BPAI compared with the controls. The inter-hemispheric functional connectivity between the supplementary motor areas was reduced bilaterally. CONCLUSIONS: The resting-state inter-hemispheric functional connectivity of the bilateral M1 areas is altered in patients after contralateral C7 nerve transfer, suggesting a functional reorganization of cerebral cortex.

Donor-side morbidity after contralateral C-7 nerve transfer: results at a minimum of 6 months after surgery.

OBJECT Donor-side morbidity associated with contralateral C-7 (CC7) nerve transfer remains controversial. The purpose of this study was to evaluate functional deficits in the donor limb resulting from prespinal route CC7 nerve transfer. METHODS A total of 63 patients were included. Forty-one patients had undergone CC7 nerve transfer surgery at least 6 months previously and were assigned to one of 2 groups based on the duration of postoperative follow-up. Group 1 (n = 21) consisted of patients who had undergone surgery between 6 months and 2 years previously, and Group 2 (n = 20) consisted of patients who had undergone surgery more than 2 years previously. An additional 22 patients who underwent CC7 nerve transfer surgery later than those in Groups 1 and 2 were included as a control group (Group 3). Results of preoperative testing in these patients and postoperative testing in Groups 1 and 2 were compared. Testing included subjective assessments and objective examinations. An additional 3 patients had undergone surgery more than 6 months previously but had severe motor weakness and were therefore evaluated separately; these 3 patients were not included in any of the study groups. RESULTS The revised Short-Form McGill Pain Questionnaire (SF-MPQ-2) was the only subjective test that showed a significant difference between Group 3 and the other 2 groups, while no significant differences were found in objective sensory, motor, or dexterity outcomes. The interval from injury to surgery for patients with a normal SF-MPQ-2 score in Groups 1 and 2 was significantly less than for those with abnormal SF-MFQ-2 scores (2.4 ± 1.1 months vs 4.6 ± 2.9 months, p = 0.002). The 3 patients with obvious motor weakness showed a tendency to gradually recover. CONCLUSIONS Although some patients suffered from long-term sensory disturbances, resection of the C-7 nerve had little effect on the function of the donor limb. Shortening preoperative delay time can improve sensory recovery of the donor limb.

Arytenoid adduction with nerve-muscle pedicle transfer vs arytenoid adduction with and without type I thyroplasty in paralytic dysphonia.

IMPORTANCE: Optimal glottal closure as well as symmetrical vocal fold masses and tensions are essential prerequisites for normal voice production. Successful phonosurgery depends on restoring these prerequisites to achieve long-term improvement. OBJECTIVE: To evaluate the efficacy of the laryngeal framework surgical treatments (arytenoid adduction with and without thyroplasty type I [AA ± Th-I]) compared with arytenoid adduction combined with nerve-muscle pedicle flap transfer (AA + NMP) in unilateral vocal fold paralysis. Patterns of voice outcome were compared over a 2-year period. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of clinical records of 22 patients who presented to an institutional practice with severe paralytic dysphonia between March 1999 and December 2008, who received 2 different treatments. Postoperative follow-up was conducted over 2 years. INTERVENTIONS: Eleven patients were treated with AA ± Th-I and 11 patients were treated with AA + NMP. MAIN OUTCOMES AND MEASURES: Vocal function was evaluated preoperatively and at 3, 12, and 24 months postoperatively. Vocal parameters evaluated were jitter, shimmer, harmonics to noise ratio (HNR), maximum phonation time (MPT), and overall grade and breathiness grade of the Grade-Roughness-Breathiness-Asthenia-Strain (GRBAS) voice scale. The outcomes of voice measurements were compared within each group across time and among the 2 groups at each time point. RESULTS: All voice parameters showed initial postoperative improvement in both groups after 3 months. Moreover, the AA + NMP group showed significant steady improvement over the 2-year follow-up, which did not occur in the AA ± Th-I group. In the AA + NMP group, MPT increased from a mean (SD) of 5.4 (2.1) s at preoperative assessment to 21.5 (7.0) s at 24 months; jitter decreased from 8.6% (5.3%) to 1.2% (0.7%); shimmer decreased from 13.1% (6.0%) to 4.0% (1.6%); HNR increased from 3.8 (3.3) to 9.0 (0.8); overall grade of GRBAS decreased from 2.4 (0.9) to 0.2 (0.4); and breathiness grade of GRBAS decreased from 2.0 (1.0) to 0.1 (0.3). CONCLUSIONS AND RELEVANCE: Unlike the conventional laryngeal framework surgical treatments, AA + NMP provided long-term voice improvement with nearly normal voice quality. Thus, it can be considered an effective surgical treatment for paralytic dysphonia due to unilateral vocal fold paralysis associated with large glottal gap.

Repairing the ventral root is sufficient for simultaneous motor and sensory recovery in multiple complete cervical root transection injuries.

AIM: In multiple cervical root transection injuries, motor and sensory recovery has been demonstrated after repairing both dorsal and ventral roots with autologous grafts applied to the dorsal and ventral aspects, respectively. However, in clinical situations, autologous grafts may not be sufficient to repair both roots in this situation. In this study, the authors evaluated whether repairing ventral root alone is sufficient for simultaneous sensory and motor function recovery. MAIN METHODS: In the transected group, the left 6th-8th cervical roots were pulled and transected at the spinal cord junction. In the repair group, the transected root was anastomosed to a single autologous nerve graft, which was inserted into the ventral horn through a pial incision. Acidic fibroblast growth factor mixed with fibrin glue was applied to the surgical area. Motor function, sensory function, cortical somatosensory evoked potentials (SSEPs), axon tracing, and CGRP(+) fibers were evaluated. KEY FINDINGS: The repaired rats exhibited simultaneous sensory and motor function recovery. At the 16th weeks, SSEPs reappeared in all animals of the repair group, but not in the transected group. Retrograde axon tracing demonstrated an increased number of sensory neurons in the dorsal root ganglia and regenerating nerve fibers in the dorsal horn. CGRP(+) fibers were significantly increased in the repair group and restricted to laminae I and II. SIGNIFICANCE: This is the first report that in multiple root avulsions with insufficient grafts, repairing ventral roots alone leads to both sensory recovery and motor recovery. This finding may help patients with multiple cervical root avulsions.

Thoracodorsal nerve graft for reconstruction of facial nerve branching.

OBJECT: Surgical treatment of parotid malignancies may frequently involve facial nerve amputation to achieve oncological radical resection. The entire facial nerve branching from its exit from the stylomastoid foramen to the periphery of the gland is often sacrificed. The first reconstructive strategy is the immediate reconstruction of the facial nerve by directly anastomosing the trunk of the facial nerve to its distal branches by interpositional nerve grafting. The present study was performed to determine the adequacy of thoracodorsal nerve grafting for immediate repair of the facial nerve. The anatomical features of the thoracodorsal nerve make it particularly appropriate to match its trunk to the stump of the facial nerve at its exit from the stylomastoid foramen. Up to seven branches of the thoracodorsal nerve may be distally anastomosed to the severed distal branches of the facial nerve. More complex reconstruction may be addressed simultaneously by contemporary harvesting a de-epithelialized free flap from the same site based on thoracodorsal vessel perforators and preparing a rib graft from the same donor site. METHODS: Between October 2003 and August 2010, seven patients affected by parotid tumors (6 with parotid malignancies and 1 with multiple recurrences of pleomorphic adenoma) underwent radical parotidectomy with intentional sacrifice of the facial nerve to obtain oncological radical resection. In all patients, the facial nerve was reconstructed with an interpositional thoracodorsal nerve graft. In four patients, a de-epithelialized free flap based on the latissimus dorsi was transposed to cover soft tissue defects. Moreover, two of these patients also required a rib graft to reconstruct both the condyle and ramus of the mandible. With the exception of one patient affected by recurrent pleomorphic adenoma, all patients underwent radiotherapy after surgical treatment. RESULTS: All patients in our study recovered mimetic facial function. Facial muscles showed clinical signs of recovery within 5-14 (mean: 7.8) months, with varying degrees of mimetic restoration, and almost complete facial symmetry at rest in all patients. The House-Brackmann final score was I in two patients, II in two patients, and III in three patients. CONCLUSIONS: A thoracodorsal nerve graft to replace extratemporal facial nerve branching is a valid alternative technique to multiple classical nerve grafts, with good matching at both the proximal and distal anastomoses.

Transhemispheric cortical plasticity following contralateral C7 nerve transfer: a rat functional magnetic resonance imaging survival study.

PURPOSE: To perform contralateral C7 nerve transfer in a controlled, survival rat functional magnetic resonance imaging model, so as to understand the extent of cortical plasticity after brachial plexus injury and surgical manipulation with this procedure. METHODS: A total of 24 rats divided into 3 groups underwent surgery followed by functional magnetic resonance imaging in this study. Group I rats served as sham controls. Group II injury rats underwent complete right brachial plexus root avulsion. Group III repair rats underwent complete right brachial plexus root avulsion and then contralateral C7 nerve transfer to the right median nerve. We assessed cortical response to median nerve stimulation at 0, 3, and 5 months after injury using functional magnetic resonance imaging at 9.4 T. We concurrently performed sensory and motor functional testing. RESULTS: We noted a progression in cortical activation in the repair rats over 0, 3, and 5 months. Initially, right median nerve stimulation in the repair group showed complete loss of activation in the contralateral somatosensory cortex. Nerve stimulation at 3 months produced primarily ipsilateral cortical activation; at 5 months, 3 patterns of cortical activation emerged: ipsilateral, bilateral, and contralateral activation. After right median nerve stimulation, injury rats maintained a lack of cortical activation and control rats maintained exclusive contralateral activation throughout all time points. Functional testing revealed a degree of return of sensory and motor function over time in the repair group compared with the injured group. CONCLUSIONS: A high degree of transhemispheric cortical plasticity occurred after contralateral C7 nerve transfer. There appears to be a predilection for the rat brain to restore the preinjury somatotopic representation of the brain. CLINICAL RELEVANCE: Understanding the cortical changes after nerve injury and repair may lead to specific pharmacologic or behavioral interventions that can improve functional outcomes.

Different functional reorganization of motor cortex after transfer of the contralateral C7 to different recipient nerves in young rats with total brachial plexus root avulsion.

Clinically, contralateral C7 transfer is used for nerve reconstruction in brachial plexus injuries. Postoperatively, synchronous motions at the donor limb are noteworthy. This study studied if different recipient nerves influenced transhemispheric functional reorganization of motor cortex after this procedure. 90 young rats with total root avulsion of the brachial plexus were divided into groups 1-3 of contralateral C7 transfer to anterior division of the upper trunk, to both the musculocutaneous and median nerves, and to the median nerve, respectively. After reinnervation of target muscles, number of sites for forelimb representations in bilateral motor cortices was determined by intracortical microstimulation at 1.5, 3, 6, 9, and 12 months postoperatively. At nine months, transhemispheric reorganization of nerves neurotized by contralateral C7 was fulfilled in four of six rats in group 1, one of six in group 2 and none in group 3, respectively; at 12 months, that was fulfilled in five of six in group 1, four of six in groups 2 and 3, respectively. Logistic regression analysis showed that rate of fulfilled transhemispheric reorganization in group 1 was 12.19 times that in group 3 (95% CI 0.006-0.651, p=0.032). At 12 months, number of sites for hindlimb representations which had encroached upon original forelimb representations on the uninjured side was statistically more in group 3 than in group 2 (t=9.5, p<0.0001). It is concluded that contralateral C7 transfer to upper trunk or to both the musculocutaneous and median nerves induces faster transhemispheric functional reorganization of motor cortex than that to median nerve alone in rats.

Nerve-muscle pedicle flap implantation combined with arytenoid adduction.

OBJECTIVES: To describe a new technique of nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction (AA) to treat dysphonia due to unilateral vocal fold paralysis and to examine postoperative vocal function. STUDY DESIGN: Retrospective review of clinical records. SETTING: Tertiary academic center. PATIENTS: Twenty-two consecutive patients underwent NMP flap implantation with AA and were followed up short term over a period of 1 to 6 months (mean, 2.9 months) and long term over a period of 7 to 36 months (mean, 21.4 months). INTERVENTIONS: An NMP flap was made using an ansa cervicalis branch and a piece of the sternohyoid muscle. A window was opened in the thyroid ala at the level of the vocal fold. Then, AA was performed and the NMP flap was securely implanted onto the thyroarytenoid muscle through the window under microscopic guidance. MAIN OUTCOME MEASURES: The maximum phonation time, mean airflow rate, pitch range, and acoustic parameters (jitter, shimmer, and harmonics to noise ratio) were evaluated before surgery and twice after surgery. RESULTS: All parameters improved significantly after surgery (P < .01). The measurements for maximum phonation time, mean airflow rate, and harmonics to noise ratio were within normal ranges after surgery. Furthermore, the maximum phonation time and jitter were significantly improved after long-term follow-up compared with early postoperative measurements (P < .01 and P < .05, respectively). CONCLUSIONS: Precise harvest of an NMP flap and its placement directly onto the thyroarytenoid muscle combined with AA provided excellent vocal function. The NMP method may have played a certain role in the improvement of postoperative vocal function, although further study with electromyographic examination is required to clarify the innervation status of the thyroarytenoid muscle.

Novel use of C7 spinal nerve for Moebius.

BACKGROUND: The purpose of this study was to introduce the use of selective ipsilateral C7 spinal nerve transfer to the armamentarium of the dynamic procedures used for facial reanimation in Moebius patients. METHODS: Between 1991 and 2007, the selective ipsilateral C7 technique was used in four patients. In three patients with bilateral paralysis, both C7 spinal nerves were utilized as nerve donors. Thus, evaluation of outcomes was carried out in seven hemifaces. RESULTS: Short-term paresthesia on the index pulp of the donor upper extremity was observed in four limbs, which recovered spontaneously. Motor deficits were never noticed. Neurotization of the free-muscle transfer for smile was performed in five hemifaces, with good results in three hemifaces (p < 0.01, z = 2.61). Eye closure neurotization was made in six hemifaces, with good results in four hemifaces (p < 0.01, z = 2.88). Depressor neurotization was made in one case and resulted in improved depressor complex function. In two cases of free muscle transfer for masseter substitution, electromyographic interpretations revealed full motor activity after bilateral latissimus dorsi transfer. Tongue neurotization was performed in two instances. Postoperatively, the patients' speech intelligibility improved as well as tongue motility and bulk. CONCLUSION: The use of the C7 as a motor donor in Moebius cases with multicranial nerve involvement supplies the typical mask-like face with an abundance of motor fibers for facial reanimation and, if there is a coexisting twelfth nerve palsy, for speech restoration.