Anatomical and Technical Considerations in Fascicular Nerve Transfers for Foot Drop.

BACKGROUND: Foot drop is the common endpoint for a diverse set of nerve injuries, affecting over 128,000 in the United States each year. The level of injury, finite pace of regeneration, and/ exponential decay in the percentage of motor end-plates reinnervated over time may explain the limited success with natural recovery. Past nerve techniques have also been met with limited success. METHODS: This narrative review explores why past nerve techniques have failed to correct foot drop. RESULTS: Previously described nerve transfer techniques suffer from incompletely balancing the foot and ankle, poor donor-target nerve synergy, and/or not effectively bypassing the wide and oftentimes underappreciated zone of injury. For maximal stability, one should look to balance the foot in both dorsiflexion and eversion. Detailed descriptions and illustrations of the branching anatomy for the peroneal and tibial nerves are provided, with specific application to nerve transfer reconstruction. CONCLUSION: Based on an understanding of why past nerve techniques have failed to correct foot drop, a set of surgical principles can be codified to optimize functional outcomes. A surgical technique should be versatile enough to address foot drop from any of the three common pathways of injury (lumbar spine, sciatic nerve, and common peroneal nerve). With increasing familiarity using this once poorly understood anatomical region, limitations with past nerve transfer techniques may be overcome.

Differential Diagnosis of "Foot Drop": Implications for Peripheral Nerve Surgery.

BACKGROUND: At least 128,000 patients in the United States each year suffer from foot drop. This is a debilitating condition, marked by the inability to dorsiflex and/or evert the affected ankle. Such patients are rendered to a lifetime of relying on an ankle-foot orthosis (AFO) for walking and nighttime to prevent an equinovarus contracture. METHODS: This narrative review explores the differential diagnosis of foot drop, with a particular focus on clinical presentation and recovery, whether spontaneously or through surgery. RESULTS: Contrary to popular belief, foot drop can be caused by more than just insult to the common peroneal nerve at the fibular head (fibular tunnel). It is a common endpoint for a diverse spectrum of nerve injuries, which may explain its relatively high prevalence. From proximal to distal, these conditions include lumbar spine nerve root damage, sciatic nerve palsy at the sciatic notch, and common peroneal nerve injury at the fibular head. Each nerve condition is marked by a unique clinical presentation, frequency, likelihood for spontaneous recovery, and cadre of peripheral nerve techniques. CONCLUSION: The ideal surgical technique for treating foot drop, other than neurolysis for compression, remains elusive as traditional peripheral nerve procedures have been marred by a wide spectrum of functional results. Based on a careful understanding of why past techniques have achieved limited success, we can formulate a working set of principles to help guide surgical innovation moving forward, such as fascicular nerve transfer.

Diagnostic Accuracy of Manual Muscle Testing to Identify Nerve Transfer Candidates in Children with Acute Flaccid Myelitis.

BACKGROUND: Manual muscle testing is a mainstay of strength assessment despite not having been compared with intraoperative electrical stimulation of peripheral nerves. METHODS: Intraoperative electrical stimulation served as the reference standard in evaluating predictive accuracy of the Active Movement Scale (AMS) and the Medical Research Council (MRC) scale. Retrospective consecutive sampling of all patients with AFM who underwent exploration or nerve transfer at a pediatric multidisciplinary brachial plexus and peripheral nerve center from March of 2016 to July of 2020 were included. The nonparametric area under the curve (AUC) was calculated. Optimal cutoff score (Youden J ) and diagnostic accuracy values were reported. The AMS and MRC scale were directly compared for predictive superiority. RESULTS: A total of 181 upper extremity nerves (73 donor nerve candidates and 108 recipient nerve candidates) were tested intraoperatively from 40 children (mean age ± SD, 7.9 ± 4.9 years). The scales performed similarly ( P = 0.953) in classifying suitable donor nerves with satisfactory accuracy (AUC AMS , 71.5%; AUC MRC , 70.7%; optimal cutoff, AMS >5 and MRC >2). The scales performed similarly ( P = 0.688) in classifying suitable recipient nerves with good accuracy (AUC AMS , 92.1%; AUC MRC :, 94.9%; optimal cutoff, AMS ≤3 and MRC ≤1). CONCLUSIONS: Manual muscle testing is an accurate, noninvasive means of identifying donor and recipient nerves for transfer in children with acute flaccid myelitis. The utility of these results is in minimizing unexpected findings in the operating room and aiding in the development of contingency plans. Further research may extend these findings to test the validity of manual muscle testing as an outcome measure of the success of nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Surgical Complexity and Physician Compensation: An Analysis of Relative Under-Valuation for Pediatric Brachial Plexus Surgery.

BACKGROUND: Brachial plexus reconstruction (BPR) is a rapidly advancing field within hand surgery. BPR procedures are complex, time-intensive, and require microsurgical expertise. As physician reimbursement rates for BPR are poorly defined, relative to more common hand procedures, we sought to analyze compensation for BPR across different payor groups and understand the factors contributing to their reimbursement. METHODS: A retrospective review was performed of surgeries by a single senior staff member in a 4-year period to evaluate Current Procedural Terminology (CPT) codes from BPR cases. For comparison, all finger fracture fixations and skin graft reconstructions performed by the same surgeon over the same time period were analyzed as well. RESULTS: A total of 57 BPR cases, 94 finger fracture fixation cases, and 69 skin grafting cases met inclusion criteria. Among the top 5 insurance providers, average work relative value unit (wRVU)/hour was 6.55, 3.49, and 12.67 for BPR, fracture fixation, and skin grafts, respectively. Reimbursements were an average $685.76/hour for BPR, compared to $590.10/hour for fracture fixation and $1,197.94/hour for skin grafts. CONCLUSIONS: BPR demonstrates a relative undervaluation, in terms of reimbursement per hour, given the time and surgical skill required for such cases, particularly compared to shorter, less complex cases such as skin grafting and fracture fixation. We find that this discrepancy is amplified across multiple levels of coding, billing, and reimbursement. We suggest specific strategies for physician leadership to more directly participate in the financial decisions that affect themselves, their patients, and their specialty.

Amyloid Deposition: An Unusual Case of Deep Gluteal Syndrome and Sciatic Nerve Compression: A Case Report.

CASE: Soft-tissue amyloidomas are exceedingly rare, with only a few cases reported in the literature. There are no reports of sciatic nerve compression secondary to a soft-tissue amyloidoma. We report a unique case of a 71-year-old man with an incidentally found amyloidoma who was initially believed to have deep gluteal syndrome. He had a favorable outcome after surgical decompression. CONCLUSION: For patients who do not have classic examination and electromyography/nerve conduction findings of piriformis syndrome, providers should explore other etiologies of peripheral nerve compression including soft-tissue amyloidoma.

Does acute flaccid myelitis cause respiratory failure in children?

INTRODUCTION: Acute flaccid myelitis (AFM) is a rare disease that affects spinal cord gray matter, results in acute flaccid weakness of one or more limbs and predominantly involves the cervical spinal cord, which places patients at higher risk for respiratory failure. Our study aims to describe respiratory failure in pediatric AFM patients with emphasis on the need for assisted ventilation and respiratory nerve involvement from an acute and long-term perspective. MATERIALS AND METHODS: We reviewed the medical records of patients diagnosed with AFM seen in a multidisciplinary clinic for persistent limb weakness between 2016 and 2020. RESULTS: We studied 54 patients, 35% were female. The median age of patients at illness onset was 5 years (range 7 months-19 years). The median age of patients at the time of study was 8.5 years (range 2-20 years). Eleven patients (20%) required assisted ventilation for acute respiratory failure. Of those that experienced acute respiratory failure, 81% developed chronic respiratory failure. Fifty-six percent of patients with chronic respiratory failure were able to wean off assisted ventilation by 1 year. All patients that experienced unilateral diaphragm impairment with AFM onset experienced acute and chronic respiratory failure. DISCUSSION: Many patients with AFM may experience respiratory compromise and develop chronic respiratory failure. However, most of these patients can be weaned off ventilatory support by 1 year from illness onset. Most children with unilateral diaphragm impairment can sustain adequate ventilation without the need for long-term ventilatory support.

Validating Grading of Aesthetic Outcomes of Web Space Reconstruction for Finger Syndactyly: Crowdsourcing Public Perceptions Using Amazon Mechanical Turk.

BACKGROUND: It has recently been attempted in the literature to analyze the aesthetic outcomes of syndactyly web space reconstruction utilizing dorsal pentagonal advancement flaps and dorsal rectangular flaps with skin grafting. The study utilized a categorical grading system for evaluating the aesthetic outcomes of reconstruction to be used in conjunction with a visual analog scale (VAS), which has yet to be validated in the assessment of aesthetic outcomes following web space reconstruction. OBJECTIVES: To utilize crowdsourced public perceptions to validate the grading of aesthetic outcomes in web space reconstruction for finger syndactyly. METHODS: A prospective study was conducted of random volunteers recruited through an internet crowdsourcing service to gain responses for a survey to analyze patient opinions toward the aesthetic outcomes of web space reconstruction. Outcomes were graded based on descriptions of the appearance, color, matte, and distortion of the reconstruction. RESULTS: The excellent dorsal flap demonstrated a mean VAS score of 6.66 (95% confidence interval [CI] = 6.45-6.87), and the very good, good, and poor dorsal flaps had mean VAS scores of 5.94 (95% CI = 5.73-6.15), 4.98 (95% CI = 4.77-5.19), and 3.55 (95% CI = 3.31-3.79), respectively. The odds ratio for receiving an excellent rating was 4.21 (95% CI = 3.04-5.82) for excellent dorsal flap with P < 0.0001. CONCLUSIONS: This study confirms and validates the assessment of aesthetic outcomes of web space reconstruction by the Yuan Grading Scale. This evidence may guide future practice such that recommendations can be made to align with the aesthetic preferences of the patient.

Recommendations for Therapy following Nerve Transfer for Children with Acute Flaccid Myelitis.

AIM: To provide recommendations for pre- and post-operative occupational and physical therapy for children with acute flaccid myelitis (AFM). METHODS: Writing panel members consisted of an interdisciplinary team of seven healthcare professionals specializing in the care of children with AFM. The panel reviewed background material on AFM, nerve transfer, and rehabilitation principles applied to pediatrics. Recommendations were prioritized if evidence was available. Where there was no known evidence to support a recommendation, this was noted. RECOMMENDATIONS: Communication and coordination among interprofessional team members are vital to a comprehensive family-centered rehabilitation program. Surgical planning should include team preparation accounting for frequency, duration, and timing of treatment, as well as individual characteristics and developmental status of the child. Recommendations for pre-operative and six phases of post-operative therapy address assessment, strengthening, range of motion, orthoses, performance of functional activity, and support of the family. CONCLUSION: Rehabilitation following nerve transfer in children with AFM requires interdisciplinary collaboration and a multisystem approach to assessment and treatment. As new evidence becomes available, recommendations may be revised or replaced accordingly.

Characteristics of Upper Extremity Recovery in Acute Flaccid Myelitis: A Case Series.

BACKGROUND: Clinical characteristics and timing associated with nonsurgical recovery of upper extremity function in acute flaccid myelitis are unknown. METHODS: A single-institution retrospective case series was analyzed to describe clinical features of acute flaccid myelitis diagnosed between October of 2013 and December of 2016. Patients were consecutively sampled children with a diagnosis of acute flaccid myelitis who were referred to a hand surgeon. Patient factors and initial severity of paralysis were compared with upper extremity muscle strength outcomes using the Medical Research Council scale every 3 months up to 18 months after onset. RESULTS: Twenty-two patients with acute flaccid myelitis (aged 2 to 16 years) were studied. Proximal upper extremity musculature was more frequently and severely affected, with 56 percent of patients affected bilaterally. Functional recovery of all muscle groups (≥M3) in an individual limb was observed in 43 percent of upper extremities within 3 months. Additional complete limb recovery to greater than or equal to M3 after 3 months was rarely observed. Extraplexal paralysis, including spinal accessory (72 percent), glossopharyngeal/hypoglossal (28 percent), lower extremity (28 percent), facial (22 percent), and phrenic nerves (17 percent), was correlated with greater severity of upper extremity paralysis and decreased spontaneous recovery. There was no correlation between severity of paralysis or recovery and patient characteristics, including age, sex, comorbidities, prodromal symptoms, or time to paralysis. CONCLUSIONS: Spontaneous functional limb recovery, if present, occurred early, within 3 months of the onset of paralysis. The authors recommend that patients without signs of early recovery warrant consideration for early surgical intervention and referral to a hand surgeon or other specialist in peripheral nerve injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Future of Upper Extremity Spasticity Management.

Surgical management of upper limb spasticity has traditionally tackled the downstream effects at the muscle, tendon, and joint levels. Because this approach does not address the underlying pathologic condition within the nerve, surgical outcomes have been marked by unsatisfactory relapse over time. Future management may focus on reestablishing a normal neuronal impulse pathway to the dysfunctional musculotendinous unit. By severing the faulty γ-neuronal circuit at the C7 level, spasticity may be reduced. Transfer of the contralateral C7 nerve root to the injured C7 nerve root may open the potential for simultaneously restoring extension and improving reach and grasp functions.

A Systematic Review of Prognostic Factors for Sensory Recovery After Digital Nerve Reconstruction.

BACKGROUND: Successful digital nerve repair is crucial in preventing painful neuroma formation and restoring sensory function after traumatic hand injury. The purpose of this study is to identify prognostic factors affecting sensory recovery following digital nerve reconstruction. METHODS: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including studies reporting patients 18 years and older, greater than 10 reconstructed digital nerves, and greater than or equal to 3 months follow-up. Studies with proximal nerve injuries in the same distribution or inadequate sensory data were excluded. Included studies were evaluated by methodological index for nonrandomized studies score. Possible predictors were examined using the t test and 1-way analysis of variance with α ≤ 0.05. RESULTS: Twenty-five studies met the inclusion criteria, consisting of 818 surgically reconstructed digital nerves (mean age, 38 years; 78% male) with a mean ± SD defect length of 1.5 ± 0.5 cm. Mean follow-up time was 22 months. Fifty-six percent of patients presented with concomitant injuries to tendons (31%) and the digital artery (13%). Mean ± SD time to surgical repair was 36 ± 73.8 days. Reconstructive techniques included 35% end-to-end primary neurorrhaphy, 31% nerve grafts, and 11% synthetic conduits. Postoperatively, 81% of the patients demonstrated sensory recovery of S3+/S4, with 45% complaining of hyperesthesia. Nerve reconstructions performed within 15 days of injury had significantly better static 2-point discrimination than delayed procedures (P = 0.02). Static 2-point discrimination measurements were also significantly better for shorter defect lengths (<1.3 cm, P = 0.05). No significant functional differences were found across age, follow-up time, injured digit or side, nor reconstructive technique. CONCLUSIONS: Digital nerve reconstruction has good to excellent sensory recovery in up to 81% of patients with improved results in nerve gaps less than 1.3 cm. Performing the reconstruction within 15 days of injury is also correlated with improved sensory recovery.

Recovery of Elbow Flexion after Nerve Reconstruction versus Free Functional Muscle Transfer for Late, Traumatic Brachial Plexus Palsy: A Systematic Review.

BACKGROUND: In late presentation of brachial plexus trauma, it is unclear whether donor nerves should be devoted to nerve reconstruction or reserved for free functional muscle transfer. The authors systematically reviewed recovery of elbow flexion after nerve reconstruction versus free functional muscle transfer for late, traumatic brachial plexus palsy. METHODS: A systematic review was performed using the PubMed, Embase, and Cochrane databases to identify all cases of traumatic brachial plexus palsy in patients aged 18 years or older. Patients who underwent late (≥12 months) nerve reconstruction or free functional muscle transfer for elbow flexion were included. Age, time to operation, and level of brachial plexus injury were recorded. British Medical Research Council grade for strength and range of motion were evaluated for elbow flexion. RESULTS: Thirty-three studies met criteria, for a total of 103 patients (nerve reconstruction, n = 53; free functional muscle transfer, n = 50). There were no differences across groups regarding surgical age (time from injury) and preoperative elbow flexion. For upper trunk injuries, 53 percent of reconstruction patients versus 100 percent of muscle transfer patients achieved grade M3 or greater strength, and 43 percent of reconstruction patients versus 70 percent of muscle transfer patients achieved grade M4 or greater strength. Of the total brachial plexus injuries, 37 percent of reconstruction patients versus 78 percent of muscle transfer patients achieved grade M3 or greater strength, and 16 percent of reconstruction patients versus 46 percent of muscle transfer patients achieved grades M4 or greater strength. CONCLUSION: In late presentation of traumatic brachial plexus injuries, donor nerves should be reserved for free functional muscle transfer to restore elbow flexion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Investigation Into the Optimal Number of Intercostal Nerve Transfers for Musculocutaneous Nerve Reinnervation: A Systematic Review.

BACKGROUND: The purpose of this study was to systematically review outcomes following intercostal nerve (ICN) transfer for restoration of elbow flexion, with a focus on identifying the optimal number of nerve transfers. METHODS: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify studies describing ICN transfers to the musculocutaneous nerve (MCN) for traumatic brachial plexus injuries in patients 16 years or older. Demographics were recorded, including age, time to operation, and level of brachial plexus injury. Muscle strength was scored based upon the British Medical Research Council scale. RESULTS: Twelve studies met inclusion criteria for a total of 196 patients. Either 2 (n = 113), 3 (n = 69), or 4 (n = 11) ICNs were transferred to the MCN in each patient. The groups were similar with regard to patient demographics. Elbow flexion ≥M3 was achieved in 71.3% (95% confidence interval [CI], 61.1%-79.7%) of patients with 2 ICNs, 67.7% (95% CI, 55.3%-78.0%) of patients with 3 ICNs, and 77.0% (95% CI, 44.9%-93.2%) of patients with 4 ICNs ( P = .79). Elbow flexion ≥M4 was achieved in 51.1% (95% CI, 37.4%-64.6%) of patients with 2 ICNs, 42.1% (95% CI, 29.5%-55.9%) of patients with 3 ICNs, and 48.4% (95% CI, 19.2%-78.8%) of patients with 4 ICNs ( P = .66). CONCLUSIONS: Previous reports have described 2.5 times increased morbidity with each additional ICN harvest. Based on the equivalent strength of elbow flexion irrespective of the number of nerves transferred, 2 ICNs are recommended to the MCN to avoid further donor-site morbidity.

Nerve Transfer versus Interpositional Nerve Graft Reconstruction for Posttraumatic, Isolated Axillary Nerve Injuries: A Systematic Review.

BACKGROUND: The purpose of this study was to compare functional outcomes between nerve grafting and nerve transfer procedures in the setting of isolated, posttraumatic axillary nerve injuries. METHODS: A systematic review was performed using the PubMed, Scopus, and Cochrane databases to identify all cases of isolated, posttraumatic axillary nerve injuries in patients aged 18 years or older. Patients who underwent axillary nerve reconstruction were included and categorized by technique: graft or transfer. Demographics were recorded, including age, time to operation, and presence of concomitant injuries. Functional outcomes were evaluated, including British Medical Research Council strength and range of motion for shoulder abduction. RESULTS: Ten retrospective studies met criteria, for a total of 66 patients (20 nerve grafts and 46 nerve transfers). Median time from injury to operation was equivalent across the nerve graft and nerve transfer groups (8.0 months versus 7.0 months; p = 0.41). Postoperative follow-up was 24.0 months for nerve grafting versus 18.5 months for nerve transfer (p = 0.13). Clinically useful shoulder abduction, defined as British Medical Research Council grade M3 or greater, was obtained in 100 percent of nerve graft patients versus 87 percent of nerve transfer patients (p = 0.09). Grade M4 or better strength was obtained in 85 percent of nerve graft patients and 73.9 percent of nerve transfer patients (p = 0.32). CONCLUSIONS: Significant differences in functional outcomes between nerve graft and transfer procedures for posttraumatic axillary nerve injuries are not apparent at this time. Prospective outcomes studies are needed to better elucidate whether functional differences do exist. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Clinical Factors Associated with the Non-Operative Airway Management of Patients with Robin Sequence.

BACKGROUND: The indications for surgical airway management in patients with Robin sequence (RS) and severe airway obstruction have not been well defined. While certain patients with RS clearly require surgical airway intervention and other patients just as clearly can be managed with conservative measures alone, a significant proportion of patients with RS present with a more confusing and ambiguous clinical course. The purpose of this study was to describe the clinical features and objective findings of patients with RS whose airways were successfully managed without surgical intervention. METHODS: The authors retrospectively reviewed the medical charts of infants with RS evaluated for potential surgical airway management between 1994 and 2014. Patients who were successfully managed without surgical intervention were included. Patient demographics, nutritional and respiratory status, laboratory values, and polysomnography (PSG) findings were recorded. RESULTS: Thirty-two infants met the inclusion criteria. The average hospital stay was 16.8 days (range, 5-70 days). Oxygen desaturation (<70% by pulse oximetry) occurred in the majority of patients and was managed with temporary oxygen supplementation by nasal cannula (59%) or endotracheal intubation (31%). Seventy-five percent of patients required a temporary nasogastric tube for nutritional support, and a gastrostomy tube placed was placed in 9%. All patients continued to gain weight following the implementation of these conservative measures. PSG data (n=26) demonstrated mild to moderate obstruction, a mean apneahypopnea index (AHI) of 19.2±5.3 events/hour, and an oxygen saturation level <90% during only 4% of the total sleep time. CONCLUSIONS: Nonsurgical airway management was successful in patients who demonstrated consistent weight gain and mild to moderate obstruction on PSG, with a mean AHI of <20 events/hour.

Reconstructive algorithms in the pediatric population.

Reconstruction of oncologic defects in the pediatric population is a unique challenge. Differences in patient comorbidities, size of the reconstructive components, response of the skeletally immature body to surgery and radiation, compliance, and overall recovery potential make the pediatric patient cohort distinct from the adult population. Considering that patients are enjoying longer life spans, it behooves the surgeon to reconstruct oncologic defects with durable and long-lasting tissue. Determining when to implement each of the reconstructive tools is based upon principles embodied by the reconstructive ladder and taking into account the defect-specific characteristics, including location and type of tissues involved. Within the setting of multi-disciplinary care, reconstruction can be associated with good long-term functional and aesthetic outcomes. J. Surg. Oncol. 2016;113:940-945. © 2016 Wiley Periodicals, Inc.

Surgical Treatment of Pediatric Upper Limb Spasticity: The Wrist and Hand.

The wrist and hand are essential in the placement of the upper extremity in a functional position for grasp, pinch, and release activities. This depends on the delicate balance between the extrinsic and intrinsic muscles of the wrist and hand. Spasticity alters this equilibrium, limiting the interaction of the upper limb with the environment. Classically, pediatric patients with upper limb spasticity present with a flexed wrist, thumb-in-palm, and flexed finger posture. These contractures are typically secondary to spasticity of the extrinsic flexor muscles of the wrist and hand and intrinsic muscles of the thumb and digits. Tendon release, lengthening, or transfer procedures may help correct the resultant abnormal postures. A total wrist arthrodesis with or without proximal row carpectomy may help address the severely flexed wrist deformity. With proper diagnosis, a well-executed surgical plan, and a consistent hand rehabilitation regimen, successful surgical outcomes can be achieved.

Surgical Treatment of Pediatric Upper Limb Spasticity: The Shoulder.

The shoulder joint is essential for placing the hand in a functional position for reach and overhead activities. This depends on the delicate balance between abductor/adductor and internal/external rotator muscles. Spasticity alters this equilibrium, limiting the interaction of the upper limb with the environment. Classically, pediatric patients with upper limb spasticity present with an adduction and internal rotation contracture of the shoulder. These contractures are typically secondary to spasticity of the pectoralis major and subscapularis muscles and sometimes attributed to the latissimus dorsi muscle. Fractional lengthening, Z-step lengthening, or tendon release of the contributing muscle groups may help correct the adduction and internal rotation contractures. With proper diagnosis, a well-executed surgical plan, and a consistent hand rehabilitation regimen, successful surgical outcomes can be achieved.