Variations of the extrapsoas course of the lumbar plexus with implications for the lateral transpsoas approach to the lumbar spine: a cadaveric study.

BACKGROUND: Together with an increased interest in minimally invasive lateral transpsoas approach to the lumbar spine goes a demand for detailed anatomical descriptions of the lumbar plexus. Although definitions of safe zones and essential descriptions of topographical anatomy have been presented in several studies, the existing literature expects standard appearance of the neural structures. Therefore, the aim of this study was to investigate the variability of the extrapsoas portion of the lumbar plexus in regard to the lateral transpsoas approach. METHODS: A total of 260 lumbar regions from embalmed cadavers were utilized in this study. The specimens were dissected as per protocol and all nerves from the lumbar plexus were morphologically evaluated. RESULTS: The most common variation of the iliohypogastric and ilioinguinal nerves was fusion of these two nerves (9.6%). Nearly in the half of the cases (48.1%) the genitofemoral nerve left the psoas major muscle already divided into the femoral and genital branches. The lateral femoral cutaneous nerve was the least variable one as it resembled its normal morphology in 95.0% of cases. Regarding the variant origins of the femoral nerve, there was a low formation outside the psoas major muscle in 3.8% of cases. The obturator nerve was not variable at its emergence point but frequently branched (40.4%) before entering the obturator canal. In addition to the proper femoral and obturator nerves, accessory nerves were present in 12.3% and 9.2% of cases, respectively. CONCLUSION: Nerves of the lumbar plexus frequently show atypical anatomy outside the psoas major muscle. The presented study provides a compendious information source of the possibly encountered neural variations during retroperitoneal access to different segments of the lumbar spine.

Superficial branch of the radial nerve passing through the supinator canal, emerging between the extensor digitorum and abductor pollicis longus muscles and consequently supplying the second finger and radial portion of the third finger: a case report and clinical implications.

Awareness of unique path of the superficial branch of the radial nerve and its unusual sensory distribution can help avoid potential diagnostic confusion. We present a unique case encountered during a routine dissection of a Central European male cadaver. An unusual course of the superficial branch of the radial nerve was found in the right forearm, where the superficial branch of the radial nerve originated from the radial nerve distally, within the supinator canal, emerged between the extensor digitorum and abductor pollicis longus muscles and supplied the second and a radial half of the third digit, featuring communications with the lateral antebrachial cutaneous nerve and the dorsal branch of the ulnar nerve. Due to dorsal emerging of the superficial branch of the radial nerve the dorsal aspect of the thumb was innervated by the lateral antebrachial cutaneous nerve. To our best knowledge such variation of the superficial branch of the radial nerve has never been reported before. This variation dramatically changes aetiology and manifestation of possible entrapment syndromes which clinicians should be aware of.

Decompression alone versus decompression with instrumented fusion in the treatment of lumbar degenerative spondylolisthesis: a systematic review and meta-analysis of randomised trials.

OBJECTIVE: To determine the efficacy of adding instrumented spinal fusion to decompression to treat degenerative spondylolisthesis (DS). DESIGN: Systematic review with meta-analysis. DATA SOURCES: MEDLINE, Embase, Emcare, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations & Theses Global, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform from inception to May 2022. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials (RCTs) comparing decompression with instrumented fusion to decompression alone in patients with DS. Two reviewers independently screened the studies, assessed the risk of bias and extracted data. We provide the Grading of Recommendations, Assessment, Development and Evaluation assessment of the certainty of evidence (COE). RESULTS: We identified 4514 records and included four trials with 523 participants. At a 2-year follow-up, adding fusion to decompression likely results in trivial difference in the Oswestry Disability Index (range 0-100, with higher values indicating greater impairment) with mean difference (MD) 0.86 (95% CI -4.53 to 6.26; moderate COE). Similar results were observed for back and leg pain measured on a scale of 0 to 100, with higher values indicating more severe pain. There was a slightly increased improvement in back pain (2-year follow-up) in the group without fusion shown by MD -5·92 points (95% CI -11.00 to -0.84; moderate COE). There was a trivial difference in leg pain between the groups, slightly favouring the one without fusion, with MD -1.25 points (95% CI -6.71 to 4.21; moderate COE). Our findings at 2-year follow-up suggest that omitting fusion may increase the reoperation rate slightly (OR 1.23; 0.70 to 2.17; low COE). CONCLUSIONS: Evidence suggests no benefits of adding instrumented fusion to decompression for treating DS. Isolated decompression seems sufficient for most patients. Further RCTs assessing spondylolisthesis stability are needed to determine which patients would benefit from fusion. PROSPERO REGISTRATION NUMBER: CRD42022308267.

Spinal fusion for single-level SPECT/CT positive lumbar degenerative disc disease: the SPINUS I study.

INTRODUCTION AND PURPOSE: With current imaging modalities and diagnostic tests, identifying pain generators in patients with non-specific chronic low back pain (CLBP) is difficult. There is growing evidence of the effectiveness of SPECT/CT examination in diagnosing the source of pain in the spine. The study aims to investigate the effect of posterior interbody fusion on a single-level SPECT/CT positive lumbar degenerative disc disease (DDD). MATERIAL AND METHODS: This is a prospective study of patients with chronic low back pain (CLBP) operated on for a single-level SPECT/CT positive DDD. Primary outcomes were changes in visual analogue scale (VAS) scores and the Oswestry Disability Index (ODI). Secondary outcomes were complications, return to work, satisfaction and willingness to re-undergo surgery. RESULTS: During a 3-year period, 38 patients underwent single-level fusion surgery. The mean preoperative VAS score of 8.4 (± 1.1) decreased to 3.2 (± 2.5, p < 0.001) and the mean preoperative ODI of 51.5 (± 7.3) improved to 20.7 (± 14.68, p < 0.001) at a 2-year follow-up. A minimum clinically important difference (30% reduction in VAS and ODI) was achieved in 84.2% of patients. Some 71% of patients were satisfied with the surgery results and 89.4% would undergo surgery again. There were four complications, and two patients underwent revision surgery. Some 82.9% of patients returned to work. CONCLUSION: Fusion for one-level SPECT/CT positive lumbar DDD resulted in substantial clinical improvement and satisfaction with surgical treatment. Therefore, SPECT/CT imaging could be useful in assessing patients with CLBP, especially those with unclear MRI findings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04876586.

Type-III Hangman's fracture combined with serious cerebrovascular injury after near-hanging: a first case report and review of the literature.

Cervical fractures are rare after non-judicial hangings. Type-III Hangman's fracture (HF) is an unstable injury caused typically by motor vehicle accidents or falls. We describe the first reported case of a Type-III HF combined with occlusion of the right vertebral artery and non-occlusive dissection of both internal carotid arteries caused by near-hanging. We performed a posterior approach open reduction of dislocated C2 facets and C1 to C3 fusion. Carotid dissections were managed conservatively with long-term antiplatelet therapy. The patient survived without any neurological deficit and without any significant restriction of cervical motion.

Possible donor nerves for axillary nerve reconstruction in dual neurotization for restoring shoulder abduction in brachial plexus injuries: a systematic review and meta-analysis.

Restoring shoulder abduction is one of the main priorities in the surgical treatment of brachial plexus injuries. Double nerve transfer to the axillary nerve and suprascapular nerve is widely used and considered the best option. The most common donor nerve for the suprascapular nerve is the spinal accessory nerve. However, donor nerves for axillary nerve reconstructions vary and it is still unclear which donor nerve has the best outcome. The aim of this study was to perform a systematic review on reconstructions of suprascapular and axillary nerves and to perform a meta-analysis investigating the outcomes of different donor nerves on axillary nerve reconstructions. We conducted a systematic search of English literature from March 2001 to December 2020 following PRISMA guidelines. Two outcomes were assessed, abduction strength using the Medical Research Council (MRC) scale and range of motion (ROM). Twenty-two studies describing the use of donor nerves met the inclusion criteria for the systematic review. Donor nerves investigated included the radial nerve, intercostal nerves, medial pectoral nerve, ulnar nerve fascicle, median nerve fascicle and the lower subscapular nerve. Fifteen studies that investigated the radial and intercostal nerves met the inclusion criteria for a meta-analysis. We found no statistically significant difference between either of these nerves in the abduction strength according to MRC score (radial nerve 3.66 ± 1.02 vs intercostal nerves 3.48 ± 0.64, p = 0.086). However, the difference in ROM was statistically significant (radial nerve 106.33 ± 39.01 vs. intercostal nerve 80.42 ± 24.9, p < 0.001). Our findings support using a branch of the radial nerve for the triceps muscle as a donor for axillary nerve reconstruction when possible. Intercostal nerves can be used in cases of total brachial plexus injury or involvement of the C7 root or posterior fascicle. Other promising methods need to be studied more thoroughly in order to validate and compare their results with the more commonly used methods.

Permanent twelfth nerve palsy secondary to C0 and C1 fracture in patient with craniocervical pneumatisation.

INTRODUCTION: Craniocervical pneumatisation of both occiput and upper cervical vertebrae is extremely rare. Although it was stated that hyperpneumatisation can lead to fracture, only few cases of such injuries have been reported. Generally, craniocervical fractures represent a small number of cervical spine injuries and they are usually caused by high-energy trauma and can be associated with lower cranial nerves palsy. CASE REPORT: We present here a case of healthy man with mostly left sided pneumatisation of occiput and C1 who suffered from fractures of occipital condyle and posterior arch of C1 associated with permanent hypoglossal nerve injury. Both fractures were stable and he was treated conservatively with a rigid collar. CONCLUSION: At follow-up, the patient reported no pain and no restriction in head movement. Total hypoglossal nerve palsy remained unchanged. Conservative treatment is a method of choice in such cases.

The economic and psychological impact of cancellations of elective spinal surgeries in the COVID-19 era.

BACKGROUND: The adoption of health care restrictions due to the COVID-19 pandemic led to the cancellation of elective surgical care. However, the impact on patients is unknown. OBJECTIVE: To evaluate the psychological and economic impact of the cancellation of scheduled spinal operations. METHODS: We identified 50 patients with cancelled surgeries between 16 March 2020 and 24 April 2020. Forty-nine (98%) participants were contacted, with whom the modified WES-Pi questionnaire was filled in during a telephone interview. RESULTS: Of the 49 respondents, 28 (57.2%) were aged <65 years. The most often reported problem (85.7%) was an ongoing limitation in basic daily activities. At least moderate sadness was experienced by 65.3% and disappointment by 73.5% of the patients. More than 80% reported concerns about the continuation and 73.5% about the progression of their symptoms. Out of 27 employees (55.1%), 63% could not work due to severe pain or movement limitation (p < .001). The inability to work was associated with anger (p = .037). The work-related impact of the cancellation was associated with stress (p < .0001) and concerns about continuing the symptoms (p = .004). Two-third of patients would undergo immediate surgery despite the current epidemic situation. CONCLUSIONS: The cancellations of elective spinal surgeries have a serious psychological impact on patients. This together with potential economic consequences is especially evident in employees unable to work due to pain or movement disability. The information is beneficial for health management. Every effort should be made to resume planned surgical treatment if the epidemiological situation allows it.

Epidemiology, etiology, and types of severe adult brachial plexus injuries requiring surgical repair: systematic review and meta-analysis.

The literature describing epidemiology, etiology, and types of serious brachial plexus injuries (BPIs) is sparse. The aim of this review was to investigate the epidemiological and etiopathogenetical data of serious BPIs undergoing surgical reconstruction. A systematic search was conducted from January 1985 to December 2017. All studies that reported data about prevalence of specific types and causes of BPIs in adults treated surgically were included and cumulatively analyzed. Ten studies including 3032 patients were identified. The pooled prevalence of closed BPIs was 93% (95% CI: 87-97%), lacerations accounted for 3% (95% CI: 1-6%), and gunshot wounds (GSWs) for 3% (95% CI: 0-7%). The prevalence of male patients was 93% (95% CI: 90-96%) and female cases 7% (95% CI: 4-10%). The most common cause of closed BPI was motorcycle accidents with 67% (95% CI: 49-82%) prevalence followed by car crashes with 14% (95% CI: 8-20%). Other causes were rare. Ninety percent (95% CI: 78-98%) of patients suffered from a supraclavicular or combined supra-/infraclavicular trauma, while 10% (95% CI: 2-22%) from isolated infraclavicular injury. The prevalence of complete lesions was 53% (95% CI: 47-58%) followed by upper plexus lesion with 39% (95% CI: 31-48%) and lower plexus injury with 6% (95% CI: 1-12%). This meta-analysis demonstrates that the typical patient suffering from severe BPI is a male after motorcycle accident with closed supraclavicular injury causing complete or slightly less commonly upper plexus palsy. Lacerations and GSWs of brachial plexus are rare.

[Surgical treatment of lower extremity peripheral nerve injuries]. / Chirurgická lécba poranení nervu dolních koncetin.

Peripheral nerve injuries of the lower extremities are not frequent. The most common are traction injury of the peroneal nerve at the knee level or iatrogenic trauma of the pelvic nerves during abdominal surgery. Civil sharp injuries are rare.Indications for surgical revision follow the general rules of nerve surgery. Sharp injury should be treated as soon as possible, ideally within 72 hours. Closed lesions are indicated for surgery if a complete denervation remains unchanged three months after the injury. Best results can be achieved within six months from the injury. Irritations caused by bone fragments or scarring or by iatrogenic injury (clamps, cement, screws, etc.) may be revised later. However, the most important is early clinical examination in a specialized neurosurgical department.

Usefulness of screening tools in the evaluation of long-term effectiveness of DREZ lesioning in the treatment of neuropathic pain after brachial plexus injury.

BACKGROUND: Despite high success rate of DREZ lesioning in the treatment of intractable central pain, there is still a significant incidence of patients without satisfactory post-operative effect. The aim of the study was to evaluate the long-term effect of DREZ lesioning using both a subjective assessment using a visual analog scale (VAS) to quantify residual pain and an assessment using the screening tool (painDETECT Questionnaire, PD-Q). METHODS: DREZ lesioning was performed in 52 patients from a total 441 cases with brachial plexus injury (11.8%) during a 17-year period (1995-2011). The effect of surgery was retrospectively assessed in 48 patients. RESULTS: A decrease in pre-operative pain by more than 75% (Group I) was achieved in 70.8% of patients and another 20.8% reported significant improvement (Group II). The surgery was unsucessful in 8.4% (Group III). We found a significant correlation between 'improvement' groups from both methods of assessments. Patients from Group I usually complained of residual nociceptive pain according to PD-Q, patients from Group II typically had pain of unclear origin, and all cases those in Group III suffered from neuropathic pain, Cramer's V = .66, P < .001. Overall, 66.7% of patients had resolved neuropathic pain, 20.8% patients had more serious complaints and may also suffer from residual neuropathic pain, while 12.5% had unresolved neuropathic pain. CONCLUSION: DREZ lesioning is a safe and effective method with success rates of about 90%. PD-Q scores correspond to subjective satisfaction with the surgery and it seems to be a suitable screening tool for finding patients with residual neuropathic pain after surgery.

Superficial branch of the radial nerve regularly contains fibers from the lateral antebrachial cutaneous nerve: A role in neuroma treatment.

BACKGROUND: Many surgical strategies aim to treat the symptomatic neuroma of the superficial branch of the radial nerve (SBRN). It is still difficult to treat despite many attempts to reveal a reason for surgical treatment failure. The lateral antebrachial cutaneous nerve (LACN) is known to overlap and communicate with SBRN. Our study aims to determine the frequency of spreading of LACN fibers into SBRN branches through a microscopic dissection to predict where and how often LACN fibers may be involved in SBRN neuroma. METHODS: Eighty-seven cadaveric forearms were thoroughly dissected. The path of LACN fibers through the SBRN branching was ascertained using microscopic dissection. Distances between the interstyloid line and entry of LACN fibers into the SBRN and emerging and bifurcation points of the SBRN were measured. RESULTS: The LACN fibers joined the SBRN at a mean distance of 1.7 ± 2.5 cm proximal to the interstyloid line. The SBRN contained fibers from the LACN in 62% of cases. Most commonly, there were LACN fibers within the SBRN's third branch (59%), but they were also observed within the first branch, the second branch, and their common trunk (21%, 9.2%, and 22%, respectively). The lowest rate of the LACN fibers was found within the SBRN trunk (6.9%). CONCLUSION: The SBRN contains LACN fibers in almost 2/3 of the cases, therefore, the denervation of both nerves might be required to treat the neuroma. However, the method must be considered based on the particular clinical situation.

Anatomical considerations of the sural nerve in the distal leg: Side branch patterns and significance in nerve harvesting procedures.

BACKGROUND: The sural nerve is a somatosensory nerve that provides sensation to the posterolateral aspect of the lower leg and the lateral part of the ankle and foot. Due to its location and anatomical properties, it is often used as an autologous nerve graft. However, the nerve harvest can be complicated by the presence of side branches. The objective of this study was to investigate the anatomy of the sural nerve and to map its side branches. This information can be used to predict the localization of separate incisions during the stair-step incisions technique for nerve harvest, thereby reducing the risk of complications. METHODS: The study involved the dissection of 50 adult cadaveric legs (25 left and 25 right) obtained from 27 Central European cadavers. The focus of the dissection was to identify the sural nerve, small saphenous vein, and surrounding anatomical structures. Detailed measurements were taken on the side branches of the sural nerve, tributaries of the small saphenous vein, and their interrelationship. RESULTS: The average number of sural nerve side branches in a single leg was 4.2±1.9. These side branches were categorized into six groups based on their location and course: mediodistal, medioproximal, lateroproximal, laterodistal, medial perpendicular, and lateral perpendicular. Specific patterns of combination of these side branches were also identified and described. The branching point of the sural nerve was found to be 5.8±2.7 cm proximal to the lateral malleolus, whereas the small saphenous vein branching point was located more distally, 4.5 ± 2.8 cm proximal to the lateral malleolus. The highest density of sural nerve side branches was found 2.1-6.0 cm above the lateral malleolus. CONCLUSION: This study presents valuable data about the relationship between the sural nerve and the surrounding anatomical structures in the distal part of the leg, including the identification of its side branches and their relevance during nerve harvest procedures. On the basis of the most frequent locations of side branches, a three-incision-technique for nerve harvest is proposed.

Clinical anatomy of the lateral antebrachial cutaneous nerve: Is there any safe zone for interventional approach?

INTRODUCTION: The lateral antebrachial cutaneous nerve (LACN) is a somatosensory nerve coursing in the lateral portion of the forearm. The nerve is located in a close proximity to the cephalic vein (CV) all along its course with a danger of being injured during venipuncture. The LACN also overlaps and communicates with the superficial branch of the radial nerve (SBRN) in the distal forearm and hand, making the awareness of their relationship of great importance in the treatment of neuroma. The aim of the study was to observe the relationship of the LACN to surrounding structures as well as its branching pattern and distribution. MATERIALS AND METHODS: Ninety-three cadaveric forearms embalmed in formaldehyde were dissected. The relationship of the LACN to surrounding structures was noted and photographed, and distances between the structures were measured with a digital caliper. The cross-sectional relationships of the LACN and SBRN to the CV were described using heatmaps. RESULTS: The emerging point of the LACN was found distally, proximally or at the level of the interepicondylar line (IEL). The LACN branched in 76 cases (81.7 %) into an anterior and posterior branch at mean distance of 47.8 ± 34.2 mm distal to the IEL. The sensory distribution was described according to the relationship of the LACN branches to the medial border of the brachioradialis muscle. The LACN supplying the dorsum of the hand was observed in 39.8 % of cases. The LACN and the SBRN intersected in 86 % of upper limbs with communications noticed in 71 % of forearms. The LACN was stated as the most frequent donor of the communicating branch resulting in neuroma located distal to the communication and being fed from the LACN. The relationship of the LACN and the CV showed that the IEL is the most appropriate place for the venipuncture due to maximal calibers of the CV and deep position of the LACN. The LACN was adjacent to the cubital perforating vein and the radial artery in all cases. The medial border of the brachioradialis muscle was observed less than 1.8 mm from the LACN. CONCLUSION: The study provides morphological data on the LACN distribution, branching pattern and relationship to surrounding structures in a context of clinical use in different spheres of medicine. The branching pattern of the LACN appears to be more constant compared to data provided by previous authors. We emphasized the meaning of cross-sectional relationship of the LACN to the CV to avoid venipuncture outside the cubital fossa if possible. The posterior branch of the LACN was predicted as appropriate donor of the graft for a digital nerve. The LACN appeared to be in a close proximity within the whole length of the brachioradialis muscle what the orthopedic surgeons must be concerned of. The meaning of the donor-nerve of the communicating branch in neuroma treatment was also introduced.

Correlation of MRI-Evaluated Degenerative Disc Disease with Positivity on Single-Photon Emission Computed Tomography Imaging in Patients with Chronic Low Back Pain.

OBJECTIVE: Chronic low back pain, affecting up to 58% of the population, often stems from intervertebral disc degeneration. Although magnetic resonance imaging (MRI) is commonly used for diagnostics, challenges arise in pinpointing pain sources due to frequent asymptomatic findings. Single-photon emission tomography (SPECT) integrated with computed tomography (CT) offers a promising approach, enhancing sensitivity and specificity. METHODS: In this retrospective study, spanning 2016 to 2022, SPECT/CT imaging was performed on 193 patients meeting specific criteria. We correlated SPECT/CT findings with lumbar MRI results, utilizing Pfirrmann and Rajasekaran classifications for disc degeneration and endplate damage assessment. Logistic regression analysis adjusted for age and sex evaluated associations. RESULTS: Of 965 spinal levels assessed, SPECT/CT positivity strongly correlated with higher Pfirrmann grades and Rajasekaran endplate classifications. Notably, Modic changes (MCs) on MRI displayed a nonsignificant relationship with SPECT/CT positivity. Significant associations were observed in older patients with positive MCs, Pfirrmann grades, and Rajasekaran classifications. CONCLUSIONS: This comprehensive study, the largest of its kind, establishes a significant link between SPECT/CT positivity and advanced lumbar degenerative changes. Higher Pfirrmann grades and increased Rajasekaran endplate damage demonstrated substantial correlations with SPECT/CT positivity. Notably, MCs did not exhibit such association. Our findings underscore the potential of SPECT/CT in identifying pain generators in degenerative spinal conditions, offering valuable insights for future interventions.

Clinical Anatomy of the Sacral Nerve Roots and Its Relevance to Their Reconstruction After Sacrectomy.

BACKGROUND AND OBJECTIVES: En bloc sacrectomy is associated with sacral root transection causing loss of urinary bladder, rectum, and sexual function. The aim of the study was to determine the position of the pudendal branches (sensorimotor) and pelvic splanchnic nerves (parasympathetic) on the sacral roots relative to the sacrum, and the minimal and maximal defects in the sacral roots that can be reconstructed by grafting after various types of sacrectomy. METHODS: Five cadaveric pelves were dissected bilaterally. The lengths and widths of the S1-S4 roots and their branches were measured. Then, the minimal and maximal defects between the proximal and distal stumps of the sacrificed roots were measured following 3 models of sacrectomy (below S2, below S1, and total sacrectomy). RESULTS: The mean distance of the splanchnic nerves from the S2 and S3 anterior sacral foramina was 17.7 ± 7.3 and 23.6 ± 11.1 mm, respectively, and the mean distance of the pudendal S2 and S3 branches was 36.8 ± 13.7 and 30.2 ± 10.8 mm, respectively. The mean widths of the S2 and S3 roots were 9.3 ± 1.9 and 5.4 ± 1.2 mm, respectively. The mean maximal defects in S2 and S3 roots after various types of sacrectomies were between 61.8 ± 16.3 and 100.7 ± 14.3 mm and between 62.7 ± 20.2 and 84.7 ± 25.1 mm, respectively. There were no statistically significant differences between sides or sexes for all obtained measurements. CONCLUSION: The reconstruction of the S2-S3 roots is anatomically feasible after partial or total sacrectomies in which the resection of the soft tissue does not extend further than approximately 1.5 to 2 cm ventrally from the sacrum.

Anterior transposition of the radial nerve to achieve primary suture for its reconstruction: Anatomical feasibility study.

INTRODUCTION: Radial nerve palsy after humeral shaft fractures is often associated with formation of a neuroma in continuity. The current standard of treatment is neuroma resection and nerve grafting with contentious results. Anterior transposition of the radial nerve may reduce the length of its path, allowing reconstruction by primary suture. The aim of this study was to determine the maximum length of radial nerve defect that can be treated by the anterior transposition to allow primary suture to be performed. METHODS: We use 10 arms from five fresh cadavers. The radial nerve was dissected in the lateral inter-muscular septum and along the anterior aspect of the forearm. The radial nerve was transected at the level of the spiral groove and both stumps were than transposed anterior to the medial inter-muscular septum. The length of tension-free overlap that could be achieved was measured. RESULTS: The average length of the overlap at zero degrees of elbow flexion was 10.00 ± 1.84 mm. Theoretically, this will allow a defect of 20 ± 3.69 mm SD to be treated by primary suture. CONCLUSION: Our results suggest that anterior transposition can be used for radial nerve defects up to 2 cm; however, dissection of both stumps proved to be challenging.

Anatomical feasibility study of the infraspinatus muscle neurotization by lower subscapular nerve.

OBJECTIVES: To investigate the anatomical feasibility of the infraspinatus branch of the suprascapular nerve (IB-SSN) reconstruction by lower subscapular nerve (LSN) transfer. METHODS: The morphological study was performed on 18 adult human cadavers. The length of the distal stump of the IB-SSN, the length of the LSN available for reconstruction and diameter of both stumps were measured. The feasibility study of the LSN to IB-SSN transfer was performed. RESULTS: The mean length of the IB-SSN to the end of its first branch was 40.9 mm (±4.6). Its mean diameter was 2.3 mm (±0.3). The mean length of the LSN stump, which was mobilized from its original course and transferred to reach the distal stump of the IB-SSN was 66.5 mm (±11.8). Its mean diameter was 2.1 mm (±0.3). The mean ratio between LSN and IB-SSN diameters was 0.9 (±0.1). The nerve transfer was feasible in 17 out of 18 cases (94.4%). CONCLUSION: This study demonstrates that direct LSN to IB-SSN transfer is anatomically feasible in most cases in the adult population. It may be used in cases of complex scapular fractures resulting in severe suprascapular nerve injury.

Is there any difference between anterior and posterior approach for the spinal accessory to suprascapular nerve transfer? A systematic review and meta-analysis.

Dual nerve transfer of the spinal accessory nerve to the suprascapular nerve (SAN-SSN) and the radial nerve to the axillary nerve is considered to be the most feasible method of restoration of shoulder abduction in brachial plexus injuries. Supraspinatus muscle plays an important role in the initiation of abduction and its functional restoration is crucial for shoulder movements. There are two possible approaches for the SAN-SSN transfer: the more conventional anterior approach and the posterior approach in the area of scapular spine, which allows more distal neurotization. Although the dual nerve transfer is a widely used method, it is unclear which approach for the SAN-SSN transfer results in better outcomes. We conducted a search of English literature from January 2001 to December 2021 using the PRISMA guidelines. Twelve studies with a total 142 patients met our inclusion criteria. Patients were divided into two groups depending on the approach used: Group A included patients who underwent the anterior approach, and Group B included patients who underwent the posterior approach. Abduction strength using the Medical Research Scale (MRC) and range of motion (ROM) were assessed. The average MRC grade was 3.57 ± 1.08 in Group A and 4.0 ± 0.65 (p = 0.65) in Group B. The average ROM was 114.6 ± 36.7 degrees in Group A and 103.4 ± 37.2 degrees in Group B (p = 0.247). In conclusion, we did not find statistically significant differences between SAN-SSN transfers performed from the anterior or posterior approach in patients undergoing dual neurotization technique for restoration of shoulder abduction.

The communication patterns between the lateral antebrachial cutaneous nerve and the superficial branch of the radial nerve.

INTRODUCTION: The superficial branch of the radial nerve (SBRN) and the lateral antebrachial cutaneous nerve (LACN) are sensory nerves coursing within the forearm in a close relationship. This high degree of overlap and eventual communication between the nerves is of great surgical importance. The aim of our study is to identify the communication pattern and overlap of the nerves, to localize the position of this communication in relation to a bony landmark, and to specify the most common communication patterns. MATERIALS AND METHODS: One hundred and two adult formalin-fixed cadaveric forearms from 51 cadavers of Central European origin were meticulously dissected. The SBRN, as well as the LACN, were identified. The morphometric parameters concerning these nerves, as well as their branches and connections, were measured with a digital caliper. RESULTS: We have described the primary (PCB) and secondary communications (SCB) between the SBRN and the LACN and their overlap patterns. One hundred and nine PCBs were found in 75 (73.53%) forearms of 44 (86.27%) cadavers and fourteen SCBs in eleven hands (10.78%) of eight cadavers (15.69%). Anatomical and surgical classifications were created. Anatomically, the PCBs were classified in three different ways concerning: (1) the role of the branch of the SBRN within the connection; (2) the position of the communicating branch to the SBRN; and (3) the position of the LACN branch involved in the communication to the cephalic vein (CV). The mean length and width of the PCBs were 17.12 mm (ranged from 2.33 to 82.96 mm) and 0.73 mm (ranged from 0.14 to 2.01 mm), respectively. The PCB was located proximally to the styloid process of the radius at an average distance of 29.91 mm (ranged from 4.15 to 97.61 mm). Surgical classification is based on the localization of the PCBs to a triangular zone of the SBRN branching. The most frequent branch of the SBRN involved in the communication was the third (66.97%). Due to the frequency and position of the PCB with the third branch of the SBRN, the danger zone was predicted. According to the overlap between the SBRN and the LACN, we have divided 102 forearms into four types: (1) no overlap; (2) present overlap; (3) pseudo-overlap; and (4) both present and pseudo-overlap. Type 4 was the most common. CONCLUSION: The patterns of communicating branch arrangements appeared to be not just a rare phenomenon or variation, but rather a common situation highlighting clinical importance. Due to the close relationship and connection of these nerves, there is a high probability of simultaneous lesion.