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1.
J Hand Surg Glob Online ; 6(5): 685-690, 2024 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-39381376

RESUMO

Long-gap nerve injuries offer unique physiological and logistical treatment challenges to the reconstructive surgeon. Options include nerve autograft, processed nerve allograft, nerve transfers, and tendon transfers. This review provides an evidence-framed discussion regarding the pros and cons of these diverse approaches.

2.
J Neurol Surg B Skull Base ; 85(5): 546-552, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-39228891

RESUMO

Objective The aim of this study was to assess the ability to smile following a hypoglossal-facial nerve transfer (N12-N7). Design This is a retrospective chart review. Setting National tertiary referral center for skull base pathology. Participants Seventeen patients. Main Outcome Measures The ability to smile following an N12-N7 transfer was assessed by five medical doctors on photographs of the whole face and frontal, orbital, and oral segments. The (segmented) photographs were scored for the symmetry, asymmetry, and correct or incorrect assessment of the affected side. Results Seventeen patients were analyzed by 5 assessors providing 85 assessments. The whole face at rest was judged symmetrical in 26% of the cases and mildly asymmetrical in 56%. Frontal, orbital, and oral segments were symmetrical in 63, 20, and 35%, respectively. The affected side was correctly identified in 76%. When smiling, the whole face was symmetrical in 6% and mildly asymmetric in 59%. The affected side was correctly identified in 94%. The frontal, orbital, and oral segments during smiling were symmetrical in 67, 15, and 6%, respectively. The affected side of the frontal, orbital, and buccal facial segments during smiling was correctly identified in 89, 89, and 96%, respectively. Interobserver variability with Fleiss' kappa analysis showed that the strength of the agreement during smile of the total face was good (0.771) Conclusion Following an N12-N7 transfer, a good facial symmetry at rest can be achieved. During smiling, almost all patients showed asymmetry of the face, which was predominantly determined by the orbital and oral segments. To improve the ability to smile after an N12-N7 transfer, additional procedures are needed.

3.
Clin Plast Surg ; 51(4): 473-483, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-39216934

RESUMO

Upper extremity peripheral nerve injuries present functional deficits that are amenable to management by tendon or nerve transfers. The principles of tendon and nerve transfers are discussed, with technical descriptions of preferred tendon and nerve transfers for radial, median, and ulnar nerve injuries.


Assuntos
Transferência de Nervo , Traumatismos dos Nervos Periféricos , Transferência Tendinosa , Extremidade Superior , Humanos , Traumatismos dos Nervos Periféricos/cirurgia , Transferência Tendinosa/métodos , Transferência de Nervo/métodos , Extremidade Superior/inervação , Extremidade Superior/cirurgia , Extremidade Superior/lesões , Nervo Ulnar/lesões , Nervo Ulnar/cirurgia , Nervo Mediano/lesões , Nervo Mediano/cirurgia , Nervo Radial/lesões , Nervo Radial/cirurgia
4.
Handb Clin Neurol ; 201: 165-181, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38697738

RESUMO

The sciatic nerve is the body's largest peripheral nerve. Along with their two terminal divisions (tibial and fibular), their anatomic location makes them particularly vulnerable to trauma and iatrogenic injuries. A thorough understanding of the functional anatomy is required to adequately localize lesions in this lengthy neural pathway. Proximal disorders of the nerve can be challenging to precisely localize among a range of possibilities including lumbosacral pathology, radiculopathy, or piriformis syndrome. A correct diagnosis is based upon a thorough history and physical examination, which will then appropriately direct adjunctive investigations such as imaging and electrodiagnostic testing. Disorders of the sciatic nerve and its terminal branches are disabling for patients, and expert assessment by rehabilitation professionals is important in limiting their impact. Applying techniques established in the upper extremity, surgical reconstruction of lower extremity nerve dysfunction is rapidly improving and evolving. These new techniques, such as nerve transfers, require electrodiagnostic assessment of both the injured nerve(s) as well as healthy, potential donor nerves as part of a complete neurophysiological examination.


Assuntos
Neuropatia Ciática , Humanos , Eletrodiagnóstico/métodos , Neuropatia Ciática/diagnóstico , Neuropatia Ciática/fisiopatologia , Neuropatia Tibial/diagnóstico
5.
Cureus ; 16(1): e52447, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-38371044

RESUMO

Functional electrical stimulation (FES) is an option to restore function in individuals after high cervical spinal cord injury (SCI) who have limited available options for tendon or nerve transfer. To be considered for FES implantation, patients must possess upper motor neuron (UMN) type denervation in potential recipient muscles, which can be confirmed by response to surface electrical stimulation during clinical evaluation. Lower motor neuron (LMN) denervated muscles will not respond to electrical stimulation and, therefore, are unavailable for use in an FES system. Previous animal studies have demonstrated that a "paralyzed" nerve transfer of a UMN-denervated motor branch to an LMN-denervated motor branch can restore electrical excitability in the recipient. In this study, we report the indications, surgical technique, and successful outcome (restoration of M3 elbow flexion) after the first "paralyzed" nerve transfer in a human patient.

6.
J Hand Surg Eur Vol ; 49(6): 783-791, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38366374

RESUMO

Selective nerve transfers are used in the setting of upper limb amputation to improve myoelectric prosthesis control. This surgical concept is referred to as targeted muscle reinnervation (TMR) and describes the rerouting of the major nerves of the arm onto the motor branches of the residual limb musculature. Aside from providing additional myosignals for prosthetic control, TMR can treat and prevent neuroma pain and possibly also phantom limb pain. This article reviews the history and current applications of TMR in upper limb amputation, with a focus on practical considerations. It further explores and identifies technological innovations to improve the man-machine interface in amputation care, particularly regarding implantable interfaces, such as muscle electrodes and osseointegration. Finally, future clinical directions and possible scientific avenues in this field are presented and critically discussed.


Assuntos
Membros Artificiais , Biônica , Músculo Esquelético , Transferência de Nervo , Extremidade Superior , Humanos , Transferência de Nervo/métodos , Extremidade Superior/inervação , Extremidade Superior/cirurgia , Músculo Esquelético/inervação , Músculo Esquelético/cirurgia , Músculo Esquelético/transplante , Amputação Cirúrgica
7.
J Hand Surg Eur Vol ; 49(6): 747-757, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38366382

RESUMO

While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.


Assuntos
Traumatismos do Nascimento , Plexo Braquial , Transferência de Nervo , Humanos , Traumatismos do Nascimento/cirurgia , Transferência de Nervo/métodos , Plexo Braquial/lesões , Neuropatias do Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/etiologia , Paralisia do Plexo Braquial Neonatal/cirurgia , Modalidades de Fisioterapia
8.
J Hand Surg Eur Vol ; 49(6): 734-746, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38366385

RESUMO

Nerve grafting, tendon transfer and joint fusion are routinely used to improve the upper limb function in patients with brachial plexus palsies. Newer techniques have been developed that provide additional options for reconstruction. Nerve transfer is a tool for restoring upper limb function in total root avulsions where nerve grafting is not possible. In partial brachial plexus injuries, nerve transfers can greatly improve shoulder, elbow, wrist and hand function. Intraoperative electrical stimulation can be used to diagnose precisely which nerve is injured and to choose which nerve fascicles should be transferred. Finally, measuring the postoperative outcome can improve the evaluation of our techniques. The aim of this article was to present the current techniques used to treat patients with brachial plexus injury.


Assuntos
Neuropatias do Plexo Braquial , Plexo Braquial , Transferência de Nervo , Humanos , Transferência de Nervo/métodos , Plexo Braquial/lesões , Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/cirurgia , Adulto , Transferência Tendinosa/métodos
9.
Acta Neurochir (Wien) ; 165(9): 2573-2580, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37479915

RESUMO

BACKGROUND: Traumatic peroneal nerve injuries are typically associated with high-energy injuries. The aim of this study was to evaluate the demographics and outcomes following surgical management of peroneal nerve injuries. METHODS: Patients evaluated at a single institution with peroneal nerve injuries between 2001 and 2022 were retrospectively reviewed. Mechanism of injury, time to surgery, pre- and postoperative examinations, and operative reports were recorded. Satisfactory outcome, defined as the ability to achieve anti-gravity dorsiflexion strength or stronger following surgery, was compared between nerve grafting and nerve transfers in patients with at least 9 months of postoperative follow-up. RESULTS: Thirty-seven patients had follow-up greater than 9 months after surgery, with an average follow-up of 3.8 years. Surgeries included neurolysis (n=5), direct repair (n=2), tibial motor nerve fascicle transfer to the anterior tibialis motor branch (n=18), or interposition nerve grafting using sural nerve autograft (n=12). At last follow-up, 59.5% (n=22) of patients had anti-gravity strength or stronger dorsiflexion. Nineteen (51.4%) patients used an ankle-foot orthosis during all or some activities. In patients that underwent nerve grafting only across the peroneal nerve defect, 44.4% (n=4) were able to achieve anti-gravity strength or stronger dorsiflexion. In patients that had a tibial nerve fascicle transfer to the tibialis anterior motor branch of the peroneal nerve, 42.9% (n=6) were able to achieve anti-gravity strength or stronger dorsiflexion at last follow-up. There was no statistical difference between nerve transfers and nerve grafting in postoperative dorsiflexion strength (p = 0.51). CONCLUSION: Peroneal nerve injuries frequently occur in the setting of knee dislocations and similar high-energy injuries. Nerve surgery is not universally successful in restoration of ankle dorsiflexion, with one-third of patients requiring an ankle-foot orthosis at mid-term follow-up. Patients should be properly counseled on the treatment challenges and variable outcomes following peroneal nerve injuries.


Assuntos
Transferência de Nervo , Traumatismos dos Nervos Periféricos , Humanos , Nervo Fibular/cirurgia , Estudos Retrospectivos , Nervo Tibial , Traumatismos dos Nervos Periféricos/cirurgia
10.
Semin Plast Surg ; 37(2): 134-142, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-37503529

RESUMO

The management of children with brachial plexus birth injuries is complex and requires a multidisciplinary approach. In the following article, we describe our approach to evaluation and management at Nicklaus Children's Hospital. It is our aim is to elucidate nuances in management.

11.
Semin Plast Surg ; 37(2): 143-154, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-37503530

RESUMO

The care of children with brachial plexus birth injuries (BPBI) is a complex multidisciplinary endeavor. At the Shriners Hospital for Children in Philadelphia, we have sought to elevate the quality of care delivered to patients through outcomes research and collaboration with colleagues around the world. Our approach to the management of this challenging pathology has evolved time and again. Here, we describe our current approach to patient assessment and operative management in patients with BPBI and its many sequelae.

12.
Semin Plast Surg ; 37(2): 85-88, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-37503531

RESUMO

The start of Stanford's brachial plexus birth palsy (BPBP) experience dates back to 1983, when Dr. Vincent Rod Hentz visited Dr. Alain Gilbert on sabbatical. Since then, our principles of care for patients with BPBP have evolved based on our group's longitudinal experience caring for children with the entire spectrum of sequelae that arise in children with BPBP. We base our clinical decision making on frequent serial examinations and use intraoperative evoked potentials to guide surgical decisions. Here, we discuss our current principles on surgical indications, timing of surgery, and preferred techniques for secondary surgery in patients with BPBP.

13.
J Plast Reconstr Aesthet Surg ; 85: 523-533, 2023 10.
Artigo em Inglês | MEDLINE | ID: mdl-37280143

RESUMO

AIMS: We aimed to explore the effectiveness of nerve transfer as an intervention to restore neurological deficits caused by extremity tumors through direct nerve involvement, neural compression, or as a consequence of oncological surgery. METHODS: A retrospective cohort study of consecutive cases was conducted, including all patients who underwent nerve transfers to restore functional deficits in limbs following soft tissue tumor resection. The threshold for a successful nerve transfer was a BMRC motor grade of 4/5 and sensory grade of 3-3+/4 with protective sensation. RESULTS: In total, 29 nerve transfers (25 motor and 4 sensory) were completed in 11 patients, aged 12-70 years at referral, over a 6-year period to 2020. This included 22 upper limb and 3 lower limb motor nerve transfers. The timing of delayed nerve transfer reconstructions was 1-15 months following primary oncological resection, with immediate simultaneous reconstructions performed in 4 cases. The threshold for success was achieved in 82% of upper limb and 33% of lower limb motor nerve transfers, while all sensory transfers were successful in restoring protective sensation. CONCLUSION: Nerve transfer surgery, a well-established technique in restoring deficits following traumatic nerve injury, is further demonstrably relevant in extremity oncological reconstruction, especially as it can be performed remotely to the tumor location or resection site and introduces a healthy nerve or fascicle to rapidly reinnervate distal muscles without sacrificing major function. This study further illustrates the importance of early recognition and referral to specialist services where multi-disciplinary surgical resection and reconstructive planning can be conducted. LEVEL OF EVIDENCE: IV Clinical Case Series.


Assuntos
Transferência de Nervo , Neoplasias de Tecidos Moles , Humanos , Estudos Retrospectivos , Procedimentos Neurocirúrgicos , Extremidade Inferior/cirurgia
14.
J Hand Surg Am ; 48(7): 711-718, 2023 07.
Artigo em Inglês | MEDLINE | ID: mdl-36963997

RESUMO

People with spinal cord injury (SCI) prioritize hand function above all else as a reconstructive goal, yet remain a markedly undertreated population by hand surgeons. This review article provides an overview of the epidemiology of SCI and the unmet clinical need of these patients. Further, this article outlines the natural history of SCI, including the expected spontaneous recovery over time and the expectations of hand function when treated with hand therapy alone. This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of SCI and recovery and provide a rationale for when to intervene with surgery. In the last decade, this field has changed dramatically with the advent of reliable nerve transfers, making referral and surgical intervention time-sensitive. Therefore this review aims to highlight the expectations from hand therapy alone in this group, the urgent need for early referral to allow nerve transfer options to be viable, and the strategies for overcoming the barriers to these referrals. This offers the opportunity for surgeons to expand their tetraplegia practices while maximizing the considerable contributions to the hand function and quality of life of these patients.


Assuntos
Transferência de Nervo , Traumatismos da Medula Espinal , Humanos , Qualidade de Vida , Extremidade Superior/cirurgia , Mãos/cirurgia , Traumatismos da Medula Espinal/epidemiologia , Traumatismos da Medula Espinal/cirurgia , Quadriplegia/cirurgia
15.
J Hand Surg Asian Pac Vol ; 27(6): 1000-1007, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36550081

RESUMO

Background: There are numerous options available for restoration of wrist and finger extension following radial nerve palsy. The aim of this study is to conduct a systematic review of the effectiveness of nerve transfer for radial nerve palsy. Methods: Electronic literature research of PubMed, Cochrane, Scopus and Lilacs database was conducted in June 2021 using the terms 'Distal nerve transfer' AND 'Radial nerve injury' 'Radial nerve palsy' OR 'Radial nerve paresis' OR 'Median nerve transfer' OR 'wrist extensor' OR 'finger extension' OR 'thumb extension' OR 'wrist motion'. The data extracted included the study details, demographic data, procedure performed and final functional outcome according to the muscle research council scale. Results: A total of 92.59% and 56.52% had satisfactory outcome following distal nerve transfer of median nerve to restore wrist and finger extension respectively. No significant correlation was found between time to injury duration and satisfactory outcomes. Conclusions: Outcomes of nerve transfers are comparable to tendon transfers. Multi-centric studies are needed to compare the results amongst various surgical procedures described. Level of Evidence: Level III (Therapeutic).


Assuntos
Transferência de Nervo , Neuropatia Radial , Humanos , Punho/cirurgia , Transferência de Nervo/métodos , Dedos/cirurgia , Dedos/inervação , Articulação do Punho/fisiologia , Neuropatia Radial/cirurgia , Paralisia/cirurgia
16.
Cureus ; 14(9): e28737, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36211092

RESUMO

Ulnar nerve dysfunction following distal humerus fractures is a recognized phenomenon. There is no dominating consensus regarding the optimal management of the ulnar nerve during surgical intervention for these fractures between leaving the nerve in situ versus nerve transposition for better healing. Additional complexities arise in the case we present, in which there was an open fracture compounded with an ulnar nerve laceration from a traumatic injury with a machete knife. We review and discuss the management of ulnar nerve injuries associated with complex open fractures of the humerus for optimizing patient outcomes following these injuries.

17.
Surg Radiol Anat ; 44(8): 1091-1099, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35906417

RESUMO

PURPOSE: Deformities of the spastic upper limb result frequently from the association of spasticity, muscle contracture and muscle imbalance between strong spastic muscles and weak non-spastic muscles. This study was designed to evaluate the feasibility of combining selective neurectomy of the usual spastic and strong muscles together with transfer of their motor nerves to the usual weak muscles, to improve wrist and fingers motion while decreasing spasticity. METHODS: Twenty upper limbs from fresh frozen human cadavers were dissected. All motor branches of the radial and median nerve for the forearm muscles were identified. We attempted all possible end-to-end nerve transfers between the usually strong "donor" motor branches, namely FCR and PT, and the usually weak "recipient" motor branches (ERCL, ECRB, PIN, AIN). RESULTS:  The PT had two nerve branches in 80%, thus allowing selective neurectomy. The proximal PT branch could be anastomosed end-to-end in 45% (AIN) to 85% (ECRL) of cases with the potential recipient branches. The distal PT branch could be anastomosed end to end to all potential recipient nerves. The FCR had a single branch in all cases. End-to-end anastomosis was possible in 90% for the ECRL and in 100% for all other recipient branches, but sacrificed all FCR innervation, ruling out hyperselective neurectomy. CONCLUSION:  Selective neurectomies can be associated with distal nerve transfers at the forearm level in selected cases. The motor nerve to the PT is the best donor for nerve transfer combined with selective neurectomy, transferred to the ECRL, ECRB, PIN or AIN.


Assuntos
Transferência de Nervo , Cadáver , Antebraço/inervação , Antebraço/cirurgia , Humanos , Nervo Mediano/anatomia & histologia , Nervo Mediano/cirurgia , Espasticidade Muscular/cirurgia , Músculo Esquelético/inervação , Músculo Esquelético/cirurgia , Nervo Radial , Extremidade Superior
18.
Rev.chil.ortop.traumatol. ; 63(1): 40-50, apr.2022. ilus, tab
Artigo em Espanhol | LILACS | ID: biblio-1435970

RESUMO

La patología traumática del plexo braquial comprende un amplio espectro de lesiones potencialmente devastadoras para la funcionalidad de los pacientes. El objetivo del presente trabajo es realizar una revisión narrativa de la literatura enfocada en el diagnóstico y estudio de las lesiones del plexo braquial en adultos, además de entregar nociones básicas sobre el manejo de esta compleja patología


Traumatic brachial plexus injuries comprise a wide spectrum of lesions that are potentially devastating to the functionality of the patients. The aim of the present review is to perform a narrative review of the literature focused on the diagnosis and study of brachial plexus injuries in adults, in addition to providing basic guidelines on the management of this complex pathology.


Assuntos
Humanos , Plexo Braquial/lesões , Neuropatias do Plexo Braquial/cirurgia , Neuropatias do Plexo Braquial/diagnóstico , Plexo Braquial/cirurgia
19.
Exp Neurol ; 353: 114054, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35341748

RESUMO

Nerve transfers have become a powerful intervention to restore function following devastating paralyzing injuries. A major limitation to peripheral nerve repair and reconstructive strategies is the progressive, fibrotic degeneration of the distal nerve and denervated muscle, eventually precluding recovery of these targets and thus defining a time window within which reinnervation must occur. One proven strategy in the clinic has been the sacrifice and transfer of an adjacent distal motor nerve to provide axons to occupy, and thus preserve (or "babysit"), the target muscle. However, available nearby nerves are limited in severe brachial plexus or spinal cord injury. An alternative and novel proposition is the transplantation of spinal motor neurons (SMNs) derived from human induced pluripotent stem cells (iPSCs) into the target nerve to extend their axons to occupy and preserve the targets. These cells could potentially be delivered through minimally invasive or percutaneous techniques. Several reports have demonstrated survival, functional innervation, and muscular preservation following transplantation of SMNs into rodent nerves. Advances in the generation, culture, and differentiation of human iPSCs now offer the possibility for an unlimited supply of clinical grade SMNs. This review will discuss the previous reports of peripheral SMN transplantation, outline key considerations, and propose next steps towards advancing this approach to clinic. Stem cells have garnered great enthusiasm for their potential to revolutionize medicine. However, this excitement has often led to premature clinical studies with ill-defined cell products and mechanisms of action, particularly in spinal cord injury. We believe the peripheral transplantation of a defined SMN population to address neuromuscular degeneration will be transformative in augmenting current reconstructive strategies. By thus removing the current barriers of time and distance, this strategy would dramatically enhance the potential for reconstruction and functional recovery in otherwise hopeless paralyzing injuries. Furthermore, this strategy may be used as a permanent axon replacement following destruction of lower motor neurons and would enable exogenous stimulation options, such as pacing of transplanted SMN axons in the phrenic nerve to avoid mechanical ventilation in high cervical cord injury or amyotrophic lateral sclerosis.


Assuntos
Células-Tronco Pluripotentes Induzidas , Traumatismos da Medula Espinal , Axônios/fisiologia , Terapia Baseada em Transplante de Células e Tecidos , Humanos , Células-Tronco Pluripotentes Induzidas/transplante , Neurônios Motores/fisiologia , Regeneração Nervosa/fisiologia
20.
J Hand Surg Eur Vol ; 47(7): 761-765, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35225060

RESUMO

We describe the patterns of motor branches to the elbow flexors in 106 fresh-frozen cadaveric upper extremities from 53 donors of the Latin American mestizo race. We identified a 20% incidence of an accessory biceps head. The innervation patterns to this accessory head were specifically described and added to the Yang classification as Type IV for the biceps and Type III for the brachialis. The patterns arising from the musculocutaneous nerve to the biceps brachii were of Type I in 69%, Type II in 9%, Type III in 7% and Type IV in 11%, and to the brachialis of Type I in 77%, Type II in 11% and Type III in 9%. In 4%, the branches did not originate from the musculocutaneous nerve. We hypothesize that the branch to the accessory biceps head might be considered as a donor for nerve transfer in selected brachial plexus injuries.


Assuntos
Cotovelo , Transferência de Nervo , Braço/inervação , Humanos , Incidência , Músculo Esquelético/inervação , Nervo Musculocutâneo
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