Thoracic Outlet Syndrome Part II: Consensus on the Management of Neurogenic Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery.

BACKGROUND: In the first part of this report, the European Association of Neurosurgical Societies' section of peripheral nerve surgery presented a systematic literature review and consensus statements on anatomy, classification, and diagnosis of thoracic outlet syndrome (TOS) along with a subclassification system of neurogenic TOS (nTOS). Because of the lack of level 1 evidence, especially regarding the management of nTOS, we now add a consensus statement on nTOS treatment among experienced neurosurgeons. OBJECTIVE: To document consensus and controversy on nTOS management, with emphasis on timing and types of surgical and nonsurgical nTOS treatment, and to support patient counseling and clinical decision-making within the neurosurgical community. METHODS: The literature available on PubMed/MEDLINE was systematically searched on February 13, 2021, and yielded 2853 results. Screening and classification of abstracts was performed. In an online meeting that was held on December 16, 2021, 14 recommendations on nTOS management were developed and refined in a group process according to the Delphi consensus method. RESULTS: Five RCTs reported on management strategies in nTOS. Three prospective observational studies present outcomes after therapeutic interventions. Fourteen statements on nonsurgical nTOS treatment, timing, and type of surgical therapy were developed. Within our expert group, the agreement rate was high with a mean of 97.8% (± 0.04) for each statement, ranging between 86.7% and 100%. CONCLUSION: Our work may help to improve clinical decision-making among the neurosurgical community and may guide nonspecialized or inexperienced neurosurgeons with initial patient management before patient referral to a specialized center.

Reviving matrix for nerve reconstruction in rat model of acute and chronic complete spinal cord injury.

This study aimed to investigate the innovative antigliotic guiding regenerative gel (AGRG) as reviving matrix for reconnection of spinal cord defect in rat models of complete acute and chronic spinal cord injury (SCI). In acute SCI, a 2 mm segment of the spinal cord (SC) was removed at Th7-Th8. Then AGRG was injected to the gap or left untreated. In chronic SCI, a 1 mm segment of the spinal cord (SC) was removed at Th7-Th8. One month later, the injured area was cleaned from connective and scar tissue, creating a gap of 2-3 mm. Then, AGRG was injected to the gap or left untreated. Functional, electrophysiological, histological and immunohistochemical assessments were performed. In acute SCI, at week 24, 75% of AGRG group showed a somatosensory evoked potential (SEP) signal. Appearance of myelin basic protein (MBP) was observed in the injured area in the AGRG group (p < 0.1), compared to the untreated group. In chronic SCI, 24 weeks after 2nd surgery, appearance of MBP, indicating presence of myelinated axons, was observed in AGRG group, compared to the untreated group (p < 0.01). These preliminary results suggest that AGRG can serve as a vital bridging station inducing regeneration of injured SC in acute and chronic cases of paraplegia.

Thoracic Outlet Syndrome Part I: Systematic Review of the Literature and Consensus on Anatomy, Diagnosis, and Classification of Thoracic Outlet Syndrome by the European Association of Neurosurgical Societies' Section of Peripheral Nerve Surgery.

BACKGROUND: Although numerous articles have been published not only on the classification of thoracic outlet syndrome (TOS) but also on diagnostic standards, timing, and type of surgical intervention, there still remains some controversy because of the lack of level 1 evidence. So far, attempts to generate uniform reporting standards have not yielded conclusive results. OBJECTIVE: To systematically review the body of evidence and reach a consensus among neurosurgeons experienced in TOS regarding anatomy, diagnosis, and classification. METHODS: A systematic literature search on PubMed/MEDLINE was performed on February 13, 2021, yielding 2853 results. Abstracts were screened and classified. Recommendations were developed in a meeting held online on February 10, 2021, and refined according to the Delphi consensus method. RESULTS: Six randomized controlled trials (on surgical, conservative, and injection therapies), 4 "guideline" articles (on imaging and reporting standards), 5 observational studies (on diagnostics, hierarchic designs of physiotherapy vs surgery, and quality of life outcomes), and 6 meta-analyses were identified. The European Association of Neurosurgical Societies' section of peripheral nerve surgery established 18 statements regarding anatomy, diagnosis, and classification of TOS with agreement levels of 98.4 % (±3.0). CONCLUSION: Because of the lack of level 1 evidence, consensus statements on anatomy, diagnosis, and classification of TOS from experts of the section of peripheral nerve surgery of the European Association of Neurosurgical Societies were developed with the Delphi method. Further work on reporting standards, prospective data collections, therapy, and long-term outcome is necessary.

Modified Hyaluronic Acid-Laminin-Hydrogel as Luminal Filler for Clinically Approved Hollow Nerve Guides in a Rat Critical Defect Size Model.

Hollow nerve guidance conduits are approved for clinical use for defect lengths of up to 3 cm. This is because also in pre-clinical evaluation they are less effective in the support of nerve regeneration over critical defect lengths. Hydrogel luminal fillers are thought to improve the regeneration outcome by providing an optimized matrix inside bioartificial nerve grafts. We evaluated here a modified hyaluronic acid-laminin-hydrogel (M-HAL) as luminal filler for two clinically approved hollow nerve guides. Collagen-based and chitosan-based nerve guides were filled with M-HAL in two different concentrations and the regeneration outcome comprehensively studied in the acute repair rat sciatic nerve 15 mm critical defect size model. Autologous nerve graft (ANG) repair served as gold-standard control. At 120 days post-surgery, all ANG rats demonstrated electrodiagnostically detectable motor recovery. Both concentrations of the hydrogel luminal filler induced improved regeneration outcome over empty nerve guides. However, neither combination with collagen- nor chitosan-based nerve guides resulted in functional recovery comparable to the ANG repair. In contrast to our previous studies, we demonstrate here that M-HAL slightly improved the overall performance of either empty nerve guide type in the critical defect size model.

On-Site Laser Photobiomodulation Treatment of Crushed Muscle Due to Prolonged Pressure in Rats.

BACKGROUND AND OBJECTIVES: Crush injuries and prolonged pressure on muscles lead to bruises and sprains and, in most of the cases, cause distraction of the muscle and release of particles into the blood stream, causing renal and systemic complications in severe cases. Laser photobiomodulation treatment (i.e., laser phototherapy) is a method suggested to decrease the pressure damage in the first 24-48 hours after muscle injury, allowing a faster and more complete physical rehabilitation. We studied the efficacy of non-invasive laser photobiomodulation treatment as an on-site treatment for crush-injured gastrocnemius muscles, developing a moderate muscle crush injury model and aiming at decreasing damage extent while regaining physical competence faster. STUDY DESIGN/MATERIALS AND METHODS: Muscle crush injury was performed on 30 female Wistar rats using direct pressure for 10 minutes on the gastrocnemius muscle in both left and right hindlimbs. Immediately after the injury, only the left hindlimb were irradiated for 16 minutes (with 780 nm laser with a power of 250 mW, the energy at the target was 240 J, and the fluence was 1019 J/cm2 ) for 1, 3, or 7 consecutive days, and sacrificed accordingly. During the follow-up period, 1, 3, or 7 days, both gastrocnemius muscles (of the treated and untreated hindlimbs) were evaluated for electrophysiology and functionality. RESULTS: The laser photobiomodulation treatment showed a significant electrophysiological and functional recovery of the gastrocnemius muscle during the first 3 days after injury, in comparison with the untreated hindlimb. CONCLUSIONS: These preliminary results are promising, showing a significant effect of the laser photobiomodulation treatment during the first 3 days after the induction of the muscle crush injury, which is the most critical period in the clinical aspect. These findings suggest a therapeutic approach, which may help restore the muscle after crush injury.

Dynamic mapping using an electrified ultrasonic aspirator in lipomyelomeningocele and spinal cord detethering surgery-a feasibility study.

BACKGROUND: Intraoperative neurophysiologic monitoring (IONM) is an established technique and adjunct of brain and spinal lesion resection surgery. In spina bifida syndrome surgery, mapping of the surgical wound is a common and accepted method in determining the position and functionality of nerve roots of the cauda equina (CE), especially when the anatomy is not straightforward and roots are splayed across or entangled within the lesion. Here, we describe a novel technique of continuous CE mapping using an electrified cavitron ultrasonic aspirator (eCUSA) in children with lipomyelomeningocele (LMMC) lesions. METHODS: We assessed a method of dynamic CE mapping using an eCUSA as a stimulation probe. Twenty children (0.5-18 years) were included in this study, diagnosed with occult spina bifida LMMC in which the eCUSA stimulator was applied. IONM data and 2-weeks post-operative data were collected. RESULTS: LMMC lesions were located in the lumbar, sacral, and lumbosacral spine. eCUSA stimulation at 0.3-3.0 mA intensities elicited positive lower extremity muscle responses in 12 of the 20 patients included in the study. These responses allowed the surgeon real-time identification of the nerve roots tangent at the LMMC-cauda equina structure and intensive removal of the fat tissue in the area non-responding to the eCUSA stimulation. CONCLUSION: Continuous eCUSA-based stimulation of the cauda equina during LMMC resection is a feasible mapping technique with potential added value improving safety of untethering. Future studies evaluating extension of untethering, as well as the rates of retethering and long-term neurological and urological outcomes, are warranted.

Reviving Matrix for Nerve Reconstruction in Rabbit Model of Chronic Peripheral Nerve Injury With Massive Loss Defect.

Background and Aims: The aim of this study was to investigate the innovative guiding regenerative gel (GRG) and antigliotic GRG (AGRG) fillings for nerve conduits, prepared with Food and Drug Administration (FDA)-approved agents and expected to provide an alternative to autologous nerve graft and to enable reconnection of massive nerve gaps in a rabbit model of chronic peripheral nerve injury with massive loss defect that simulates the human condition of chronic injury with a large gap. Methods: The components and dosimetry for GRG and AGRG formulations were investigated in vitro on nerve cell culture and in vivo on 10-mm reconstructed sciatic nerves of 72 rats using different concentrations of agents and completed on a rabbit model of delayed (chronic) complete peripheral nerve injury with a 25-mm gap. Forty rabbits underwent delayed (9 weeks after complete injury of the tibial portion of the sciatic nerve) nerve tube reconstruction of a gap that is 25 mm long. GRG and AGRG groups were compared with autologous and empty tube reconstructed groups. Rats and rabbits underwent electrophysiological and histochemical assessments (19 weeks for rats and 40 weeks for rabbits). Results: Application of AGRG showed a significant increase of about 78% in neurite length per cell and was shown to have the most promising effect on neuronal outgrowth, with total number of neurites increasing by 4-fold. The electrophysiological follow-up showed that AGRG treatment is most promising for the reconstruction of the tibial portion of the sciatic nerve with a critical gap of 25 mm. The beneficial effect of AGRG was found when compared with the autologous nerve graft reconstruction. Thirty-one weeks post the second surgery (delayed reconstruction), histochemical observation showed significant regeneration after using AGRG neurogel, compared with the empty tube, and succeeded in significantly regenerating the nerve, as well as the autologous nerve graft, which was almost similar to a healthy nerve. Conclusion: We demonstrate that in the model of delayed peripheral nerve repair with massive loss defect, the application of AGRG led to a stronger nerve recovery and can be an alternative to autologous nerve graft.

Photobiomodulation in Neuroscience: A Summary of Personal Experience.

OBJECTIVE: This review summarizes personal experience with laser photobiomodulation and its potentials for the treatment of peripheral and central nerve system injuries. METHODS AND RESULTS: Laser photobiomodulation was shown to induce nerve cell activation, have a positive effect on metabolism of the nerve cells, and to stimulate nerve sprouting processes. Studies investigating the effects of laser photobiomodulation on injured peripheral nerves in rats reported immediate protective effects which increase the functional activity of the nerve, decrease or prevent scar tissue formation at the injured site, prevent or decrease degeneration in corresponding motor neurons of the spinal cord, and significantly increase axonal growth and myelinization. A direct application of laser on the spinal cord had a positive impact on the corresponding injured peripheral nerve and promoted recovery. A 780-nm laser phototherapy was applied following peripheral nerve reconstruction using a guiding nerve tube. Results showed myelinated axons crossing through the nerve tube and the continuation of axonal sprouting through the tube toward the distal part of the nerve. In a double-blind, placebo-controlled randomized pilot clinical trial in patients with incomplete stable long-term peripheral nerve injury (PNI), 780-nm laser irradiation progressively improved peripheral nerve function and led to substantial functional recovery. Muscle atrophy represents a major challenge in restorative medicine. Laser phototherapy was shown to increase biochemical activity and improve morphological recovery in muscle and, thus, could have a direct therapeutic application, especially during progressive muscle atrophy resulting from PNI. The effectiveness of composite implants of cultured embryonal nerve cells and the role of laser irradiation on regeneration and repair of the completely transected rat spinal cord were examined. Results suggested that laser photobiomodulation treatment accelerates the axonal growth. CONCLUSIONS: The significance of the performed experimental and clinical studies is in the provision of new laser technology in field of cell therapy and its therapeutic value for peripheral nerve and spinal cord injuries. Additional well-designed clinical studies are needed to evaluate the effectiveness and role of laser photobiomodulation treatment in a clinical setting.

Muscle Response to Complete Peripheral Nerve Injury: Changes of Acetylcholine Receptor and Creatine Kinase Activity over Time.

Background This study was designed to assess the changes of acetylcholine receptor (AChR) and creatine kinase (CK) levels, which are important biochemical markers for muscle viability in cases of long-term muscle denervation. Scientists and peripheral nerve surgeons may find these data important regarding maximal range of muscle viability applicable for timing of effective peripheral nerve reconstructive surgery. Methods The study was conducted on 48 rats (96 gastrocnemius muscles), whose right legs were denervated by removing a 10-mm segment of sciatic nerve, while their left legs remained intact. Under general anesthesia, the rats were euthanized at seven points in time, on days 7, 14, 21, 30, 60, 120, and 210. In both legs, AChR was quantified by 125I-α-bungarotoxin, whereas CK activity was measured using a spectrophotometric method. Results CK levels in the denervated limb reached a minimal level of 34% on day 30 in comparison to the intact limb and remained at this level up to 210 days after operation. AChR levels in the denervated limb reached a minimal level of 38% on day 120 in comparison to the intact limb and remained at this level up to 210 days after operation. Conclusion The present study shows that AChR and CK levels in rat denervated muscles remain constant at about third of its intact condition for a period of at least a third of rat's lifetime postinjury.

Photobiomodulation Triple Treatment in Peripheral Nerve Injury: Nerve and Muscle Response.

BACKGROUND: Muscle preservation or decrease in muscle degeneration and progressive atrophy are major challenges in patients with severe peripheral nerve injury (PNI). Considerable interest exists in the potential therapeutic value of laser phototherapy (photobiomodulation) for restoring denervated muscle atrophy and for enhancing regeneration of severely injured peripheral nerves. As previously published, the laser phototherapy has a protective and immediate effect in PNI. Laser phototherapy in the early stages of muscle atrophy may preserve the denervated muscle by maintaining creatinine kinase (CK) activity and the amount of acetylcholine receptor (AChR). OBJECTIVE AND METHODS: In the present study, the effectiveness of triple treatment laser phototherapy, namely, applied simultaneously at three areas: injured area of the peripheral nerve, corresponding segments of the spinal cord, and corresponding denervated muscle (triple treatment), was evaluated for the treatment of incomplete PNI in rats with the ultimate goal of achieving improved limb function. RESULTS: Forty-five days after the sciatic nerve insult, all rats regained normal walking (functional sciatic index values returned to baseline); however, the long laser irradiation (7 min) group presented the fastest recovery as opposed to short laser irradiation (3 min). A histological evaluation of the nerves revealed that long laser irradiation led to a higher amount of neuronal fibers that were larger than 4 µm (543 ± 76.8, p < 0.01) than short irradiation (283 ± 35.36). A histological evaluation of muscular atrophy showed that long laser irradiation evolved with significantly less muscle atrophy (8.06% ± 1.23%, p < 0.05) than short irradiation (24.44% ± 7.26%). CONCLUSIONS: The present study and our previous investigations showed that the laser phototherapy increases biochemical activity and improves morphological recovery in muscle and, thus, could have direct therapeutic applications on muscle, especially during progressive atrophy resulting from PNI.

Peripheral Nerve Regeneration Through Hydrogel-Enriched Chitosan Conduits Containing Engineered Schwann Cells for Drug Delivery.

Critical length nerve defects in the rat sciatic nerve model were reconstructed with chitosan nerve guides filled with Schwann cells (SCs) containing hydrogel. The transplanted SCs were naive or had been genetically modified to overexpress neurotrophic factors, thus providing a cellular neurotrophic factor delivery system. Prior to the assessment in vivo, in vitro studies evaluating the properties of engineered SCs overexpressing glial cell line-derived neurotrophic factor (GDNF) or fibroblast growth factor 2 (FGF-2(18kDa)) demonstrated their neurite outgrowth inductive bioactivity for sympathetic PC-12 cells as well as for dissociated dorsal root ganglion cell drop cultures. SCs within NVR-hydrogel, which is mainly composed of hyaluronic acid and laminin, were delivered into the lumen of chitosan hollow conduits with a 5% degree of acetylation. The viability and neurotrophic factor production by engineered SCs within NVR-Gel inside the chitosan nerve guides was further demonstrated in vitro. In vivo we studied the outcome of peripheral nerve regeneration after reconstruction of 15-mm nerve gaps with either chitosan/NVR-Gel/SCs composite nerve guides or autologous nerve grafts (ANGs). While ANGs did guarantee for functional sensory and motor regeneration in 100% of the animals, delivery of NVR-Gel into the chitosan nerve guides obviously impaired sufficient axonal outgrowth. This obstacle was overcome to a remarkable extent when the NVR-Gel was enriched with FGF-2(18kDa) overexpressing SCs.

Clinical aspects of ballistic peripheral nerve injury: shrapnel versus gunshot.

OBJECTIVES: Ballistic injuries to peripheral nerves pose special challenges in terms of indications, timing and type of surgical intervention. The aim of the present work was to analyze our experience in the surgical treatment of peripheral nerve ballistic injuries with respect to the mechanism of injury (gunshot versus shrapnel), and identify common and dissimilar prognostic factors in both types of injury. METHODS: This study was conducted on 42 patients totaling 58 nerves. Twenty-two patients (32 nerves) were injured by gunshot and 20 patients (26 nerves) by shrapnel. Median postoperative follow-up was 33 months (range 12 months to 14 years). RESULTS: Overall postoperative outcome appears to be more favorable for gunshot-wound (GSW) patients than shrapnel-injured patients, especially in terms of neuropathic pain relief (75 % vs. 58 % respectively, p < 0.05). Presence of foreign particles in shrapnel injured patients has a negative impact on the surgical outcome in terms of rate of pain improvement (28 % compared to 67 % in patients with and without foreign particles, respectively). Nerve graft reconstruction, rather than neurolysis, seems to be the more beneficial treatment for shrapnel-induced neuropathic pain (100 % vs. 47 % in improvement rate, respectively). Early surgical intervention (median 2 months after injury) significantly relieved neuropathic pain in 83 % of shrapnel-injured patients compared to 58 % in patients operated later. CONCLUSIONS: This study suggests that shrapnel injury is more destructive for nerve tissue than gunshot injury. Our impression is that early surgical intervention in shrapnel injuries and split nerve grafting (especially when small fragments are recognized in the nerve) significantly improve the patient's functional activity and quality of life.

Protective effect of laser phototherapy on acetylcholine receptors and creatine kinase activity in denervated muscle.

OBJECTIVE: This study was designed to assess the status of skeletal muscles after laser treatment during long-term denervation processes, by investigating changes in the level of acetylcholine receptors (AChR) and creatine kinase (CK) activity in the denervated gastrocnemius muscle of the rat. BACKGROUND DATA: Progressive muscle atrophy is common in patients with severe peripheral nerve injury. Denervated muscles can account for significant differences in the extent of AChR and CK activity during the denervation period. MATERIAL AND METHODS: The study was conducted on 96 rats: 48 that received laser treatment and 48 untreated controls. The gastrocnemius muscle was denervated by removing a 10 mm segment of the sciatic nerve. Low power laser irradiation was delivered transcutaneously to the right gastrocnemius muscle (HeNe continuous wave [CW] laser, 632.8 nm, 35 mW, 30 min) for 14 consecutive days. Under general anesthesia, the rats were euthanized at seven time points: day 7 (n=10), day 14 (n=10), day 21 (n=10), day 30 (n=5), day 60 (n=4), day 120 (n=5), and day 210 (n=4), with and without laser treatment, respectively. AChR was quantified by the (125)I-α-bungarotoxin. CK activity was measured by a specific spectrophotometric method. RESULTS: Laser treatment had a significant therapeutic effect on the denervated muscle during the first 21 days for AChR and the first 30 days for CK activity. CONCLUSIONS: In the early stages of muscle atrophy, laser phototherapy may preserve the denervated muscle by maintaining CK activity and the amount of AChR.

Peroneal and tibial intraneural ganglion cysts in children.

BACKGROUND/AIMS: Intraneural ganglion cyst is a rare and underrecognized clinical entity in the pediatric population, which may cause pain as well as motor and sensory neurological deficits. This study presents 4 pediatric patients harboring ganglion cysts involving the peroneal and tibial nerves. METHODS: Data encompassing pre- and postoperative analyses of 4 pediatric patients with intraneural ganglion cyst was evaluated. RESULTS: Out of these 4 patients, 3 had an intraneural ganglion cyst involving the peroneal nerve, and 1 patient had his tibial nerve involved. Two patients were operated for recurrent ganglion cysts with severe postoperative neurological deficits, after preceding operations in other institutions. The other 2 patients had no history of previous surgery, and they had their initial surgical treatment in our institute for primarily diagnosed ganglion cysts. With a mean follow-up of 24 months, all patients experienced pain relief. Significant improvement of motor deficits was achieved in 3 patients. No recurrences were encountered during the 24-month follow-up. CONCLUSION: Intraneural ganglion cysts in children can be treated with excellent outcome in experienced and dedicated centers, which specialize in peripheral nerve microsurgery.

Increase of neuronal sprouting and migration using 780 nm laser phototherapy as procedure for cell therapy.

BACKGROUND AND OBJECTIVES: The present study focuses on the effect of 780 nm laser irradiation on the growth of embryonic rat brain cultures embedded in NVR-Gel (cross-linked hyaluronic acid with adhesive molecule laminin and several growth factors). Dissociated neuronal cells were first grown in suspension attached to cylindrical microcarriers (MCs). The formed floating cell-MC aggregates were subsequently transferred into stationary cultures in gel and then laser treated. The response of neuronal growth following laser irradiation was investigated. MATERIALS AND METHODS: Whole brains were dissected from 16 days Sprague-Dawley rat embryos. Cells were mechanically dissociated, using narrow pipettes, and seeded on positively charged cylindrical MCs. After 4-14 days in suspension, the formed floating cell-MC aggregates were seeded as stationary cultures in NVR-Gel. Single cell-MC aggregates were either irradiated with near-infrared 780 nm laser beam for 1, 4, or 7 minutes, or cultured without irradiation. Laser powers were 10, 30, 50, 110, 160, 200, and 250 mW. RESULTS: 780 nm laser irradiation accelerated fiber sprouting and neuronal cell migration from the aggregates. Furthermore, unlike control cultures, the irradiated cultures (mainly after 1 minute irradiation of 50 mW) were already established after a short time of cultivation. They contained a much higher number of large size neurons (P<0.01), which formed dense branched interconnected networks of thick neuronal fibers. CONCLUSIONS: 780 nm laser phototherapy of embryonic rat brain cultures embedded in hyaluronic acid-laminin gel and attached to positively charged cylindrical MCs, stimulated migration and fiber sprouting of neuronal cells aggregates, developed large size neurons with dense branched interconnected network of neuronal fibers and, therefore, can be considered as potential procedure for cell therapy of neuronal injury or disease.

Phototherapy in peripheral nerve regeneration: From basic science to clinical study.

OBJECT: This review summarizes the continuous study of low-power laser radiation treatment of a severely injured peripheral nerve. Laser phototherapy was applied as a supportive factor for accelerating and enhancing axonal growth and regeneration after injury or a reconstructive peripheral nerve procedure. In nerve cell cultures, laser phototherapy was used to stimulate activation of nerve cells. METHODS: Low-power laser radiation was used for treatment of peripheral nerve injury using a rat sciatic nerve model after crush injury, neurorrhaphy, or neurotube reconstruction. Nerve cell growth and axonal sprouting were investigated using laser phototherapy on embryonic rat brain cultures. The outcome in animal studies facilitated a clinical double-blind, placebo-controlled, randomized study that measured the effectiveness of 780-nm laser phototherapy on patients suffering from incomplete peripheral nerve injuries for 6 months to several years. RESULTS: Animal studies showed that laser phototherapy has an immediate protective effect, maintains functional activity of the injured nerve, decreases scar tissue formation at the injury site, decreases degeneration in corresponding motor neurons of the spinal cord, and significantly increases axonal growth and myelinization. In cell cultures, laser irradiation accelerates migration, nerve cell growth, and fiber sprouting. A pilot clinical double-blind, placebocontrolled, randomized study showed that in patients with incomplete long-term peripheral nerve injury, 780-nm laser radiation can progressively improve peripheral nerve function, which leads to significant functional recovery. CONCLUSIONS: Using 780-nm laser phototherapy accelerates and enhances axonal growth and regeneration after injury or a reconstructive peripheral nerve procedure. Laser activation of nerve cells, their growth, and axonal sprouting can be considered as potential treatment of neuronal injury. Animal and clinical studies show the promoting action of phototherapy on peripheral nerve regeneration, making it possible to suggest that the time for broader clinical trials has arrived.

Facial nerve reconstruction using a split hypoglossal nerve with preservation of tongue function.

A prospective study conducted on 13 patients suffering from complete facial nerve injury (for 4 months up to 2 years) aimed to show that using the split hypoglossal nerve allows for reconstruction of the facial nerve with preservation of tongue function. The hypoglossal nerve was split longitudinally. For each half, a split of the hypoglossal nerve's response was measured intraoperatively by recording the compound muscle action potential of the tongue muscle. The half that showed the least response was selected for anastomosis. The facial nerve was transected at the stylomastoid foramen, and its distal part underwent a direct anastomosis with the selected half of the hypoglossal nerve. The six grades of the House-Brackman grading system were used to analyze the results. The average postoperative follow-up period was 3 years. Before surgery, 12 patients in this study were graded VI, with total paralysis, and 1 was graded V. After surgery, 2 of the 13 patients showed mild dysfunction (grade II), 7 patients showed moderate dysfunction (grade III), 3 patients showed moderately severe dysfunction (grade IV), and 1 patient showed a severe dysfunction (grade V). Microsurgical facial nerve reconstruction using a split hypoglossal nerve results in functional facial nerve improvement with preservation of tongue function.