G. Carl Huber (1865-1934): A Michigan Pioneer in Peripheral Nerve Injury and Regeneration.

The treatment of peripheral nerve injuries has seen tremendous innovations over the past century. Dr Gotthelf Carl Huber, an American immigrant and early experimental pioneer in the field of peripheral nerve injury, created a foundation of scientific knowledge for these advancements. At the beginning of his career, Huber published novel work in peripheral nerve injury, supporting the concept of Wallerian degeneration and demonstrating the use of nerve grafting for repair. As his scientific career evolved into other research areas at the University of Michigan, Huber's impact extended far beyond just the study of peripheral nerve injury. Because of the external forces of the First World War, Dr Huber's focus returned to translational projects concentrated on the treatment of neuromas and war time peripheral nerve injuries. Huber's scientific impact in the field of peripheral nerve injury and repair came as a result of his incredible work ethic, mentorship, and tremendous leadership qualities; through this, his work still influences clinical practice today, a century later.

Quantifying Patient-Initiated Upper Extremity Movement After Surgical Reconstruction for Adult Pan-Brachial Plexus Injury.

BACKGROUND AND OBJECTIVES: Determining functional recovery in adult patients with traumatic pan-brachial plexus injury (pBPI) is hampered by the fact that most outcome measures are collected in the clinical setting and may not reflect arm use in the real world. This study's objectives were to demonstrate the feasibility of using wearable motion sensor technology to quantify spontaneous arm movement in adult patients with pBPI after surgical reconstruction and report the time and intensity with which the affected arm was used. METHODS: Twenty-nine patients with pBPI who underwent surgical reconstruction at least 2 years prior were included in this study. Study participants wore an accelerometer on bilateral arms for 7 days. The vector time (VT) and magnitude with which each arm moved were collected and divided by the same values collected from the uninjured arm to generate a ratio (VT and vector magnitude [VM], respectively) to quantify differences between the arms. Correlations between VT, VM, and patient demographic and physician-elicited clinical measures were calculated. Patients were enrolled at Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan, and data analysis was performed at the University of Michigan. RESULTS: Twelve patients had pan-avulsion injuries, and 17 patients had C5 rupture with C6-T1 avulsion injuries. All underwent nerve reconstruction with contralateral C7 or ipsilateral C5 nerve roots as donors. At mean 7.3 years after surgery, the mean VT ratio was 0.54 ± 0.13 and the mean VM ratio was 0.30 ± 0.13. Both VT and VM ratios were significantly correlated with patient employment and movements at the elbow and forearm. CONCLUSION: Wearable motion detection technology can capture spontaneous, real-world movements of the arm in patients who have undergone surgical reconstruction for pBPI. Despite severe injuries, these patients are able to use their affected arm 50% of the time and with 30% of the intensity of their unaffected arm, which is positively correlated with return to work after injury. These data support the use of surgical reconstruction for pBPI.

Supraclavicular approach for neonatal brachial plexus palsy.

Neonatal brachial plexus palsy describes injury to the brachial plexus in the perinatal period, resulting in motor and sensory deficits of the upper arm. Nerve reconstruction, including graft repair and nerve transfers, can be used to restore function in patients whose injury does not respond to conservative management. Despite the availability of these techniques, 30%-40% of children have lifelong disability, reflecting a 10-fold underutilization of surgery. Here, the authors demonstrate a supraclavicular approach for brachial plexus exploration, as well as a spinal accessory to suprascapular nerve transfer for restoration of shoulder abduction and external rotation. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22109.

Defining postoperative C5 palsy and recovery: a systematic review.

OBJECTIVE: Postoperative C5 palsy (C5P) is a well-recognized and often-delayed complication of cervical spine surgery. Most patients recover within 6 months of onset, but the prognosis of severe cases is poor. The clinical significance and natural history of mild versus severe C5P appear to differ substantially, but palsy severity and recovery have been poorly characterized in the literature. METHODS: Owing to the varying prognoses and expanding treatment options such as nerve transfer surgery to reconstruct the C5 myotome, this systematic review attempted to describe how C5P severity is classified and how C5P and its recovery are defined, with the aim of proposing a postoperative C5P scale to support clinical decision-making. PubMed was searched for articles in English published since 2000 that offer a clear definition of postoperative C5P or its recovery. Only articles reporting exclusively on C5 palsy for patients undergoing surgery for degenerative disease were included. A single reviewer screened titles and abstracts and reviewed the full text of relevant articles, with consultation as needed from a second reviewer. Data collected included postoperative C5P definitions, classification of C5P severity, and definition and/or classification of C5P recovery. Qualitative analysis was performed. RESULTS: Full-text reviews were conducted of 98 of 272 articles identified and screened, and 43 met the inclusion criteria. Postoperative C5P was most commonly defined as a reduction in deltoid muscle strength by ≥ 1 grade using manual muscle testing (MMT), with potential biceps involvement also noted by some studies. The few studies that stratified C5P on the basis of severity unanimously characterized severe C5P as MMT grade ≤ 2. Nine studies reported on C5P recovery. Deltoid muscle strength improvement of MMT grade 5 commonly defined complete recovery, with no MMT improvement considered partial recovery. CONCLUSIONS: This review identified clear discrepancies in the definitions of C5P and its recovery, leading to heterogeneity in its evaluation and management. With the emergence of therapeutic procedures for severe C5P, standardization of the definitions of C5P and its recovery is critical. The authors propose MMT grades of 4, 3, and ≤ 2 to classify C5P as mild, moderate, and severe, respectively, and grades of 5, 4, and 3 to classify recovery as complete, sufficient, and useful, respectively.

Acute Flaccid Myelitis: Review of Clinical Features, Diagnosis, and Management with Nerve Transfers.

BACKGROUND: Acute flaccid myelitis (AFM) is a devastating neurologic condition in children, manifesting as acute limb weakness and/or paralysis. Despite increased awareness of AFM following initiation of U.S. surveillance in 2014, no treatment consensus exists. The purpose of this systematic review was to summarize the most current knowledge regarding AFM epidemiology, cause, clinical features, diagnosis, and supportive and operative management, including nerve transfer. METHODS: The authors systematically reviewed the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases to search the keywords ("acute flaccid myelitis"), ('acute flaccid myelitis'/exp OR 'acute flaccid myelitis'), and (Acute AND flaccid AND myelitis). Included articles reported on (1) AFM diagnosis and (2) patient-specific data regarding epidemiology, cause, clinical features, diagnostic features, or management of AFM. RESULTS: Ninety-nine articles were included in this review. The precise cause and pathophysiologic mechanism of AFM remain undetermined, but AFM is strongly associated with nonpolio enterovirus infections. Clinical presentation typically comprises preceding viral prodrome, pleocytosis, spinal cord lesions on T2-weighted magnetic resonance imaging, and acute onset of flaccid weakness/paralysis with hyporeflexia in at least one extremity. Supportive care includes medical therapy and rehabilitation. Early studies of nerve transfer for AFM have shown favorable outcomes for patients with persistent weakness. CONCLUSIONS: Supportive care and physical therapy are the foundation of a multidisciplinary approach to managing AFM. For patients with persistent limb weakness, nerve transfer has shown promise for improving function in distal muscle groups. Surgeons must consider potential spontaneous recovery, patient selection, donor nerve availability, recipient nerve appropriateness, and procedure timing.

Optimal timing of referral for nerve transfer surgery for postoperative C5 palsy.

OBJECTIVE: Cervical nerve 5 palsy can occur following surgery for cervical spine pathology. The prognosis of C5 palsy is generally favorable, and most patients recover useful function. However, some patients do not recover useful strength. Nerve transfers are a potential effective treatment of postoperative severe C5 palsy. This study aimed to further delineate the natural history of recovery from postoperative C5 palsy, determine whether lack of recovery at specific time points predicts poor recovery prognosis, and thereby determine a reasonable time point for referral to a complex peripheral nerve specialist. METHODS: The authors conducted a retrospective review of 72 patients who underwent surgery for cervical spondylosis and stenosis complicated by C5 palsy. Medical Research Council (MRC) motor strength grades were recorded preoperatively; immediately postoperatively; at discharge; and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Univariate and multivariate logistic regression models were used to identify demographic and clinical risk factors associated with recovery of useful strength after severe C5 palsy. RESULTS: The mean patient age was 62.5 years, and 36.1% of patients were female. Thirty patients (41.7%) experienced severe C5 palsy with less than antigravity strength (MRC grade 2 or less) at discharge. Twenty-one (70%) of these patients recovered useful strength (MRC grade 3 or greater) at 12 months postoperatively, and 9 patients (30%) did not recover useful strength at 12 months. Of those patients with persistent severe C5 palsy at 3 months postoperatively, 50% recovered useful strength at 12 months. Of those patients with persistent severe C5 palsy at 6 months postoperatively, 25% recovered useful strength at 12 months. No patient with MRC grade 0 or 1 strength at 6 months postoperatively recovered useful strength. A history of diabetes was associated with the occurrence of severe C5 palsy. On multivariate analysis, female sex was associated with recovery of useful strength. CONCLUSIONS: Most patients with severe C5 palsy recover useful strength in their C5 myotome within 12 months of onset. However, at 3 months postoperatively, patients with persistent severe C5 palsy had only a 50% chance of recovering useful strength by 12 months. Lack of recovery of useful strength at 3 months postoperatively is a reasonable time point for referral to a complex peripheral nerve center to establish care and to determine candidacy for nerve transfer surgery if severe C5 palsy persists.

Quantifying long-term upper-limb activity using wearable motion sensors after nerve reconstruction for neonatal brachial plexus palsy.

OBJECTIVE: Standard, physician-elicited clinical assessment tools for the evaluation of function after nerve reconstruction for neonatal brachial plexus palsy (NBPP) do not accurately reflect real-world arm function. Wearable activity monitors allow for the evaluation of patient-initiated, spontaneous arm movement during activities of daily living. In this pilot study, the authors demonstrate the feasibility of using body-worn sensor technology to quantify spontaneous arm movement in children with NBPP 10 years after nerve reconstruction and report the timing and magnitude of recovered arm movement. METHODS: Eight children with NBPP who underwent brachial plexus reconstruction approximately 10 years prior were recruited to take part in this single-institution prospective pilot study. Per the treatment protocol of the authors' institution, operated patients had severe, nonrecovering nerve function at the time of surgery. The patients were fitted with an activity monitoring device on each of the affected and unaffected arms, which were worn for 7 consecutive days. The duration (VT) and power (VM) with which each arm moved during the patient's normal daily activities were extracted from the accelerometry data and ratios comparing the affected and unaffected arms were calculated. Demographic data and standard physician-elicited clinical measures of upper-extremity function were also collected. RESULTS: Three children underwent nerve grafting and transfer and 5 children underwent graft repair only. The mean (± SD) active range of motion was 98° ± 53° for shoulder abduction, 130° ± 24° for elbow flexion, and 39° ± 34° for shoulder external rotation. The median Medical Research Council grade was at least 2.5 for all muscle groups. The median Mallet grade was at least 2 for all categories, and 13.5 total. The VT ratio was 0.82 ± 0.08 and the VM ratio was 0.53 ± 0.12. CONCLUSIONS: Wearable activity monitors such as accelerometers can be used to quantify spontaneous arm movement in children who underwent nerve reconstruction for NBPP at long-term follow-up. These data more accurately reflect complex, goal-oriented movement needed to perform activities of daily living. Notably, despite severe, nonrecovering nerve function early in life, postsurgical NBPP patients use their affected arms more than 80% of the time that they use their unaffected arms, paralleling results in patients with NBPP who recovered spontaneously. These data represent the first long-term, real-world evidence to support brachial plexus reconstruction for patients with NBPP.

Optimizing nerve transfer surgery in tetraplegia: clinical decision making based on innervation patterns in spinal cord injury.

OBJECTIVE: Nerve transfers are increasingly being utilized in the treatment of chronic tetraplegia, with increasing literature describing significant improvements in sensorimotor function up to years after injury. However, despite technical advances, clinical outcomes remain heterogenous. Preoperative electrodiagnostic testing is the most direct measure of nerve health and may provide prognostic information that can optimize preoperative patient selection. The objective of this study in patients with spinal cord injury (SCI) was to determine various zones of injury (ZOIs) via electrodiagnostic assessment (EDX) to predict motor outcomes after nerve transfers in tetraplegia. METHODS: This retrospective review of prospectively collected data included all patients with tetraplegia from cervical SCI who underwent nerve transfer at the authors' institution between 2013 and 2020. Preoperative demographic data, results of EDX, operative details, and postoperative motor outcomes were extracted. EDX was standardized into grades that describe donor and recipient nerves. Five zones of SCI were defined. Motor outcomes were then compared based on various zones of innervation. RESULTS: Nineteen tetraplegic patients were identified who underwent 52 nerve transfers targeting hand function, and 75% of these nerve transfers were performed more than 1 year postinjury, with a median interval to surgery following SCI of 24 (range 8-142) months. Normal recipient compound muscle action potential and isolated upper motor neuron injury on electromyography (EMG) were associated with greater motor recovery. When nerve transfers were stratified based on donor EMG, greater motor gains were associated with normal than with abnormal donor EMG motor unit recruitment patterns. When nerve transfers were separated based on donor and recipient nerves, normal flexor donors were more crucial than normal extensor donors in powering their respective flexor recipients. CONCLUSIONS: This study elucidates the relationship of the preoperative innervation zones in SCI patients to final motor outcomes. EDX studies can be used to tailor surgical therapies for nerve transfers in patients with tetraplegia. The authors propose an algorithm for optimizing nerve transfer strategies in tetraplegia, whereby understanding the ZOI and grade of the donor/recipient nerve is critical to predicting motor outcomes.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America.

PURPOSE: Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS: A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS: Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS: Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

Analysis of the effect of intraoperative neuromonitoring during resection of benign nerve sheath tumors on gross-total resection and neurological complications.

OBJECTIVE: The aim of this study was to examine the role of intraoperative neuromonitoring (IONM) during resection of benign peripheral nerve sheath tumors in achieving gross-total resection (GTR) and in reducing postoperative neurological complications. METHODS: Data from consecutive adult patients who underwent resection of a benign peripheral nerve sheath tumor at 7 participating institutions were combined. Propensity score matching was used to balance covariates. The primary outcomes of interest were the association between IONM and GTR and the association of IONM and the development of a permanent postoperative neurological complication. The secondary outcomes of interest were the association between IONM and GTR and the association between IONM and the development of a permanent postoperative neurological complication in the subgroup of patients with tumors involving a motor or mixed nerve. Univariate and multivariate logistic regression were then performed on the propensity score-matched samples to assess the ability of the independent variables to predict the outcomes of interest. RESULTS: A total of 337 patients who underwent resection of benign nerve sheath tumors were included. In multivariate analysis, the use of IONM (OR 0.460, 95% CI 0.199-0.978; p = 0.047) was a significant negative predictor of GTR, whereas none of the variables, including IONM, were associated with the occurrence of a permanent postoperative neurological complication. Within the subgroup of motor/mixed nerve tumors, in the multivariate analysis, IONM (OR 0.263, 95% CI 0.096-0.723; p = 0.010) was a significant negative predictor of a GTR, whereas IONM (OR 3.800, 95% CI 1.925-7.502; p < 0.001) was a significant positive predictor of a permanent postoperative motor deficit. CONCLUSIONS: Overall, 12% of the cohort had a permanent neurological complication, with new or worsened paresthesias most common, followed by pain and then weakness. The authors found that formal IONM was associated with a reduced likelihood of GTR and had no association with neurological complications. The authors believe that these data argue against IONM being considered standard of care but do not believe that these data should be used to universally argue against IONM during resection of benign nerve sheath tumors.

The Presence and Persistence of Unrealistic Expectations in Patients Undergoing Nerve Surgery.

BACKGROUND: Unrealistic expectations of the outcomes of peripheral nerve surgery reduce patient satisfaction. Most clinicians can recall patients with unrealistic expectations despite verbal preoperative education. OBJECTIVE: To assess patients' baseline level of understanding regarding nerve surgery and appropriate expectations. Additionally, we tested the effect of a written, preoperative educational handout on the patients' retention of knowledge. METHODS: This cross-sectional survey recruited patients scheduled to undergo peripheral nerve surgery at a single institution in 2016 to 2017. During the preoperative visit, a specialized nurse practitioner reviewed perioperative protocols, risks and benefits of the surgery, and postoperative care. Patients immediately completed a survey to assess their preoperative understanding of the verbally reviewed information. During the same visit, an additional written handout was given to patients in a randomized fashion. At their first postoperative visit, all patients completed the survey again. RESULTS: A total of 60 patients (mean age 52 yr) were enrolled of which 62% were male. Immediately following verbal instruction, 31% of patients had erroneous (unrealistic) expectations regarding pain, 30% had erroneous expectations regarding postoperative motor outcome, and 41% had erroneous expectations regarding the timing of postoperative recovery. There was no significant difference between patients who received the written handout vs those who did not, on retesting in the postoperative period. CONCLUSION: Patients undergoing peripheral nerve procedures demonstrated a high baseline level of unrealistic expectations despite standard in-person verbal counseling by specialty providers. A written handout did not have clear benefit in the retention of preoperative surgical teaching. Further investigation into more effective preoperative patient counseling is needed.

Nerve transfers in the upper extremity following cervical spinal cord injury. Part 1: Systematic review of the literature.

OBJECTIVE: Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia. METHODS: A systematic literature search was conducted using Ovid MEDLINE 1946-, Embase 1947-, Scopus 1960-, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed. RESULTS: Twenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months-13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month-4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension. CONCLUSIONS: Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.

Nerve transfers in the upper extremity following cervical spinal cord injury. Part 2: Preliminary results of a prospective clinical trial.

OBJECTIVE: Patients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly used to treat patients with cervical SCIs. In this article, the authors present early results of a prospective clinical trial using nerve transfers to restore upper-extremity function in tetraplegia. METHODS: Participants with American Spinal Injury Association (ASIA) grade A-C cervical SCI/tetraplegia were prospectively enrolled at a single institution, and nerve transfer(s) was performed to improve upper-extremity function. Functional recovery and strength outcomes were independently assessed and prospectively tracked. RESULTS: Seventeen participants (94.1% males) with a median age of 28.4 years (range 18.2-76.3 years) who underwent nerve transfers at a median of 18.2 months (range 5.2-130.8 months) after injury were included in the analysis. Preoperative SCI levels ranged from C2 to C7, most commonly at C4 (35.3%). The median postoperative follow-up duration was 24.9 months (range 12.0-29.1 months). Patients who underwent transfers to median nerve motor branches and completed 18- and 24-month follow-ups achieved finger flexion strength Medical Research Council (MRC) grade ≥ 3/5 in 4 of 15 (26.7%) and 3 of 12 (25.0%) treated upper limbs, respectively. Similarly, patients achieved MRC grade ≥ 3/5 wrist flexion strength in 5 of 15 (33.3%) and 3 of 12 (25.0%) upper limbs. Among patients who underwent transfers to the posterior interosseous nerve (PIN) for wrist/finger extension, MRC grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) upper limbs 18 and 24 months postoperatively, respectively. Similarly, grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) cases for thumb extension. No meaningful donor site deficits were observed. Patients reported significant postoperative improvements from baseline on upper-extremity-specific self-reported outcome measures. CONCLUSIONS: Motor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. In the authors' experience, nerve transfers for the reinnervation of hand and finger flexors showed variable functional recovery; however, transfers for the reinnervation of arm, hand, and finger extensors showed a more consistent and meaningful return of strength and function.

Quantifying Real-World Upper-Limb Activity Via Patient-Initiated Movement After Nerve Reconstruction for Upper Brachial Plexus Injury.

BACKGROUND: A critical concept in brachial plexus reconstruction is the accurate assessment of functional outcomes. The current standard for motor outcome assessment is clinician-elicited, outpatient clinic-based, serial evaluation of range of motion and muscle power. However, discrepancies exist between such clinical measurements and actual patient-initiated use. We employed emerging technology in the form of accelerometry-based motion detectors to quantify real-world arm use after brachial plexus surgery. OBJECTIVE: To evaluate (1) the ability of accelerometry-based motion detectors to assess functional outcome and (2) the real-world arm use of patients after nerve transfer for brachial plexus injury, through a pilot study. METHODS: Five male patients who underwent nerve transfer after brachial plexus injury wore bilateral motion detectors for 7 d. The patients also underwent range-of-motion evaluation and completed multiple patient-reported outcome surveys. RESULTS: The average age of the recruits was 41 yr (±17 yr), and the average time from operation was 2 yr (±1 yr). The VT (time of use ratio) for the affected side compared to the unaffected side was 0.73 (±0.27), and the VM (magnitude ratio) was 0.63 (±0.59). VT strongly and positively correlated with shoulder flexion and shoulder abduction: 0.97 (P = .008) and 0.99 (P = .002), respectively. CONCLUSION: Accelerometry-based activity monitors can successfully assess real-world functional outcomes after brachial plexus reconstruction. This pilot study demonstrates that patients after nerve transfer are utilizing their affected limbs significantly in daily activities and that recovery of shoulder function is critical.

An update on the management of adult traumatic nerve injuries-replacing old paradigms: A review.

Acute nerve injuries are routinely encountered in multisystem trauma patients. Advances in surgical treatment of nerve injuries now mean that good outcomes can be achieved. Despite this, old mantras associated with management of nerve injuries, including "wait a year to see if recovery occurs" and "there's nothing we can do", persist. Practicing by these mantras places these patients at a disadvantage. Changes begin to occur in the nerve, neuromuscular junction, and muscle from the moment a nerve injury occurs. These changes can become irreversible approximately 18 to 24 months following denervation. Thus, it is a race to reestablish a functional nerve-muscle connection before these irreversible changes. Good outcomes rely on appropriate acute management and avoiding delays in care. Primary nerve surgery options include direct primary repair, nerve graft repair, and nerve transfer. Acute management of nerve injuries proceeds according to the rule of 3's and requires early cooperation between trauma surgeons who recognize the nerve injury and consultant nerve surgeons. Care of patients with acute traumatic nerve injuries should not be delayed. Awareness of current management paradigms among trauma surgeons will help facilitate optimal upfront management. With the ever-expanding surgical options for management of these injuries and the associated improvement of outcomes, early multidisciplinary approaches to these injuries have never been more important. Old mantras must be replaced with new paradigms to continue to see improvements in outcomes for these patients. The importance of this review is to raise awareness among trauma surgeons of new paradigms for management of traumatic nerve injuries.

Comparative accuracies of electrodiagnostic and imaging studies in neonatal brachial plexus palsy.

OBJECTIVEThe incorporation of ancillary testing in the preoperative setting for patients with neonatal brachial plexus palsy (NBPP) remains controversial, but the recommendation for early nerve reconstruction when a baby has a preganglionic lesion at the lower nerve roots is generally accepted. At some specialty centers, nerve surgeons use preoperative electrodiagnostic testing (EDX) and imaging to aid in lesion localization and the preoperative planning of the nerve reconstruction. EDX and imaging have been evaluated for their abilities to detect pre- and postganglionic lesions, but their accuracies have never been compared directly in the same set of patients. The aim of the present study was to evaluate the accuracy of imaging and EDX in an NBPP population.METHODSA retrospective review was conducted of 54 patients with operative NBPP seen between 2007 and 2017. The patients underwent EDX and imaging: EDX was performed, and the results were reviewed by board-certified electrodiagnosticians, and imaging was reviewed by board-certified neuroradiologists. The gold standard was considered to be the findings at surgical exploration. Descriptive and analytical statistics were utilized to compare the accuracies of imaging and EDX.RESULTSThe mean age at surgery was 6.94 mos (± 4 mos). Fifteen patients (28%) were Narakas grade I-II, and 39 (72%) were Narakas grade III-IV. For all nerve roots, the overall accuracy of detecting preganglionic lesions was 74% for EDX and 69% for imaging. The overall sensitivity of detecting preganglionic lesions by EDX was 31%, but the specificity was 90%. The overall sensitivity of detecting preganglionic lesions by imaging was 66%, and the overall specificity was 70%. However, at C8, EDX was 37.5% sensitive and 87.5% specific, whereas imaging was 67.7% sensitive but only 29.4% specific.CONCLUSIONSEDX outperformed imaging with regard to specificity and accuracy of identifying preganglionic injuries. This finding is especially relevant in the lower nerve roots, given that lower plexus preganglionic lesions are an accepted indication for early intervention.

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review.

Importance: Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms. Observations: Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function. Conclusions and Relevance: Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Prediction Algorithm for Surgical Intervention in Neonatal Brachial Plexus Palsy.

BACKGROUND: Neonatal brachial plexus palsy (NBPP) results in reduced function of the affected arm with profound ramifications on quality of life. Advances in surgical technique have shown improvements in outcomes for appropriately selected patients. Patient selection, however, remains difficult. OBJECTIVE: To develop a decision algorithm that could be applied at the individual patient level, early in life, to reliably predict persistent NBPP that would benefit from surgery. METHODS: Retrospective review of NBPP patients was undertaken. Maternal and neonatal factors were entered into the C5.0 statistical package in R (The R Foundation). A 60/40 model was employed, whereby 60% of randomized data were used to train the decision tree, while the remaining 40% were used to test the decision tree. The outcome of interest for the decision tree was a severe lesion meeting requirements for surgical candidacy. RESULTS: A decision tree prediction algorithm was generated from the entered variables. Variables utilized in the final decision tree included presence of Horner's syndrome, presence of a pseudomeningocele, Narakas grade, clavicle fracture at birth, birth weight >9 lbs, and induction or augmentation of labor. Sensitivity of the decision tree was 0.71, specificity 0.96, positive predictive value 0.94, negative predictive value 0.79, and F1 score 0.81. CONCLUSION: We developed a decision tree prediction algorithm that can be applied shortly after birth to determine surgical candidacy of patients with NBPP, the first of its kind utilizing only maternal and neonatal factors. This conservative decision tree can be used to offer early surgical intervention for appropriate candidates.

Intraoperative Ultrasound for Peripheral Nerve Applications.

Offering real-time, high-resolution images via intraoperative ultrasound is advantageous for a variety of peripheral nerve applications. To highlight the advantages of ultrasound, its extraoperative uses are reviewed. The current intraoperative uses, including nerve localization, real-time evaluation of peripheral nerve tumors, and implantation of leads for peripheral nerve stimulation, are reviewed. Although intraoperative peripheral nerve localization has been performed previously using guide wires and surgical dyes, the authors' approach using ultrasound-guided instrument clamps helps guide surgical dissection to the target nerve, which could lead to more timely operations and shorter incisions.