Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review.

INTRODUCTION: Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP. MATERIALS AND METHODS: A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers. RESULTS: Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment. CONCLUSION: Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.

Erectile Functional Restoration With Genital Branch of Genitofemoral Nerve to Pelvic Nerve Transfer After Spinal Root Transection in Rats.

OBJECTIVE: To investigate the feasibility of erectile function restoration by the genitofemoral nerve to pelvic nerve transfer in rats. METHODS: Thirty-six male rats were included in this study. Rats in the nerve transfer group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection and then bilateral genitofemoral nerve to pelvic nerve transfer, rats in the nerve resection group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection without nerve transfer, and rats in the control group (n = 12) served as controls. After reinnervation, intracavernous pressure (ICP) assessment was performed. Fluoro-Gold was injected into the corpus cavernosum. Immediately before euthanasia, transferred nerves were stimulated to test penile intracavernous pressure. The L6, S1, and L1-2 spinal cord segments were used for retrogradely labeled neurons. Regenerative nerve morphologic examination assessment was performed. RESULTS: Genitofemoral nerve stimulation induced an increase in ICP in the nerve transfer group. The mean ICP in this group was (33.8 ± 9.4 mm Hg), which is higher than the mean value in the nerve resection group (3.9 ± 1.0 mm Hg) but lower than that in the control group (69.8 ± 12.2 mm Hg; P < .05). The formation of new neural pathways was confirmed by the appearance of Fluoro-Gold labeled neurons in the L-1 and L-2 spinal cord segments in the nerve transfer group. Regenerative nerve morphologic examination showed good axonal regeneration after genitofemoral nerve transfer. CONCLUSION: Nerve regeneration can be obtained by genitofemoral nerve to pelvic nerve transfer, and erectile function can be restored.

The Nerve to Thyrohyoid Muscle as a Novel Donor Nerve for Laryngeal Reinnervation.

OBJECTIVES: Recurrent laryngeal nerve (RLN) injury may be a consequence of surgical procedures of the skull base, neck, and chest, with adverse consequences to function and quality of life. Laryngeal reinnervation offers a potentially stable improvement in vocal fold position and tone. The classic donor nerve is the ansa cervicalis, but is not always available due to damage or sacrifice during previous neck surgeries. Our objective was to introduce the nerve to the thyrohyoid (TH) muscle as an alternate donor nerve for reinnervation, which has not previously been described. METHODS: Case series of two patients using the TH nerve for laryngeal reinnervation after RLN injury, with description of surgical harvest. RESULTS: Follow-up results are available for 10 months (one patient) and 3 years (one patient) demonstrating both subjective and objective improvement in function. GRBAS scores were reduced. Maximal phonation time was improved. Patient rating of voice was stable or improved postoperatively. One patient described significant preoperative dyspnea which was significantly improved postoperatively, from a score of 24 to 10 out of 40 on the dyspnea handicap index. VHI was improved in one patient, but scores elevated in the other, despite a change from "moderately severe impairment" to "normal voice" subjectively. Neither patient experienced significant complications from the procedure. CONCLUSION: Laryngeal reinnervation procedures provide good outcomes in pediatric patients. When ansa cervicalis is not available as a donor nerve, the nerve to TH provides a reasonable alternative.

Surface Electromyographic Biofeedback as a Rehabilitation Tool for Patients with Global Brachial Plexus Injury Receiving Bionic Reconstruction.

In patients with global brachial plexus injury and lack of biological treatment alternatives, bionic reconstruction, including the elective amputation of the functionless hand and its replacement with a prosthesis, has recently been described. Optimal prosthetic function depends on a structured rehabilitation protocol, as residual muscle activity in a patient's arm is later translated into prosthetic function. Surface electromyographic (sEMG) biofeedback has been used during rehabilitation after stroke, but has so far not been used in patients with complex peripheral nerve injuries. Here, we present our rehabilitation protocol implemented in patients with global brachial plexus injuries suitable for bionic reconstruction, starting from identification of sEMG signals to final prosthetic training. This structured rehabilitation program facilitates motor relearning, which may be a cognitively debilitating process after complex nerve root avulsion injuries, aberrant re-innervation and extra-anatomical reconstruction (as is the case with nerve transfer surgery). The rehabilitation protocol using sEMG biofeedback aids in the establishment of new motor patterns as patients are being made aware of the advancing re-innervation process of target muscles. Additionally, faint signals may also be trained and improved using sEMG biofeedback, rendering a clinically "useless" muscle (exhibiting muscle strength M1 on the British Medical Research Council [BMRC] scale) eligible for dexterous prosthetic hand control. Furthermore, functional outcome scores after successful bionic reconstruction are presented in this article.

Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol.

BACKGROUND: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.

Muscle-Nerve-Muscle Grafting for Facial Reanimation in Rats.

OBJECTIVE: Facial paralysis is a devastating condition leaving patients with a myriad of aesthetic and functional consequences. Muscle-nerve-muscle (MNM) neurotization is a reinnervation technique that involves implanting an autogenous nerve graft as a conduit between an innervated "donor" muscle and a denervated "recipient" muscle. We investigated the use of MNM reinnervation, alone or in combination with electrical stimulation (ES) and testosterone propionate (TP) in comparison to nerve reanastomosis (RE), on functional recovery following rat facial nerve injury. METHODS: Thirty-one male, Sprague-Dawley rats were assigned to groups: no graft (control), MNM grafting alone (MNM), MNM grafting with ES and TP (MNM+ES+TP), or RE. Harvested right facial nerve branches were used as the MNM graft. Functional recovery was assessed by behavioral observations and electromyographic recordings. RESULTS: The MNM grafting improved muscle tone and vibrissae movement. The ES+TP treatment further enhanced muscle tone as well as reduced recovery time for coordinated movement in a manner that is comparable to those of RE. Electromyographic recordings demonstrated electrical conductance across all MNM grafts. CONCLUSION: These data have important implications for patients with unilateral paralysis from facial or laryngeal nerve injury, particularly those who are not candidates for nerve reanastomosis.

Contemporary solutions for the treatment of facial nerve paralysis.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Understand the most modern indications and technique for neurotization, including masseter-to-facial nerve transfer (fifth-to-seventh cranial nerve transfer). 2. Contrast the advantages and limitations associated with contiguous muscle transfers and free-muscle transfers for facial reanimation. 3. Understand the indications for a two-stage and one-stage free gracilis muscle transfer for facial reanimation. 4. Apply nonsurgical adjuvant treatments for acute facial nerve paralysis. SUMMARY: Facial expression is a complex neuromotor and psychomotor process that is disrupted in patients with facial paralysis breaking the link between emotion and physical expression. Contemporary reconstructive options are being implemented in patients with facial paralysis. While static procedures provide facial symmetry at rest, true 'facial reanimation' requires restoration of facial movement. Contemporary treatment options include neurotization procedures (a new motor nerve is used to restore innervation to a viable muscle), contiguous regional muscle transfer (most commonly temporalis muscle transfer), microsurgical free muscle transfer, and nonsurgical adjuvants used to balance facial symmetry. Each approach has advantages and disadvantages along with ongoing controversies and should be individualized for each patient. Treatments for patients with facial paralysis continue to evolve in order to restore the complex psychomotor process of facial expression.

Update in facial nerve paralysis: tissue engineering and new technologies.

PURPOSE OF REVIEW: To present the recent advances in the treatment of facial paralysis, emphasizing the emerging technologies. This review will summarize the current state of the art in the management of facial paralysis and discuss the advances in nerve regeneration, facial reanimation, and use of novel biomaterials. This review includes surgical innovations in reinnervation and reanimation as well as progress with bioelectrical interfaces. RECENT FINDINGS: The last decade has witnessed major advances in the understanding of nerve injury and approaches for management. Key innovations include strategies to accelerate nerve regeneration, provide tissue-engineered constructs that may replace nonfunctional nerves, approaches to influence axonal guidance, limiting of donor-site morbidity, and optimization of functional outcomes. Approaches to muscle transfer continue to evolve, and new technologies allow for electrical nerve stimulation and use of artificial tissues. SUMMARY: The fields of biomedical engineering and facial reanimation increasingly intersect, with innovative surgical approaches complementing a growing array of tissue engineering tools. The goal of treatment remains the predictable restoration of natural facial movement, with acceptable morbidity and long-term stability. Advances in bioelectrical interfaces and nanotechnology hold promise for widening the window for successful treatment intervention and for restoring both lost neural inputs and muscle function.

Otfrid Foerster (1873-1941)--self-taught neurosurgeon and innovator of reconstructive peripheral nerve surgery.

Otfrid Foerster (1873-1941) became a self-taught neurosurgeon during and after WW I, playing a critical role in the development of peripheral nerve reconstruction. Although best known for describing dermatomes, he published over 300 articles on the nervous system. Confronted by thousands of nerve injuries during WW I, as well as poor results and disinterest from his surgical colleagues, Foerster began performing neurolysis and tension-free nerve repairs himself under emergency conditions. He pioneered grafting motor nerve defects by expendable cutaneous nerves (e.g., sural) and performed intraplexal neurotizations and various nerve transfers, such as the pectoral, subscapular, long thoracic, and thoracodorsal nerves in brachial plexus injuries. Foerster championed rehabilitation, recognizing the potential of electrostimulation and physiotherapy to influence cortical reorganization (brain plasticity) and improve recovery after nerve injury. Foerster died from tuberculosis in 1941, leaving a rich reconstructive peripheral nerve legacy; his innovative and visionary spirit serves as a role model.

Peripheral nerve: what's new in basic science laboratories.

Peripheral nerve regeneration research has unfolded a wealth of basic science knowledge in the last century. Today, that knowledge has become the fundamental groundwork for evolving clinical applications to treat peripheral nerve defects. This article discusses two clinical applications that have been investigated thoroughly in the laboratory setting for decades and recently tested in the clinical setting: nerve allotransplantation to graft nerve defects, and brief electrical stimulation to promote nerve regeneration. It also discusses the generation of Thy-1-XFP transgenic mice, which express fluorescent proteins in the nervous system and provide new avenues for investigating peripheral nerve regeneration.

Vein grafts used as nerve conduits for obstetrical brachial plexus palsy reconstruction.

BACKGROUND: Limited availability of donor nerve grafts along with donor-site morbidity has stimulated research toward other alternatives for the repair of severe nerve injuries. The authors provide a comprehensive review of "tubulization" biology and share with the readers their experience with two cases of obstetrical brachial plexus paralysis where they used vein grafts with "minced" nerve tissue, to accomplish connectivity of proximal donors with distal targets. Usage of vascular tissue as conduits for nerve regeneration was first reported more than 100 years ago. It has been suggested that the vein's wall allows diffusion of the proper nutrients for nerve regeneration, acts as a barrier against ingrowth of scar, and prevents wastage of regenerating axons. METHODS: In this report, vein grafts of 2.4, 3.5, and 22 cm in length filled with minced peripheral nerve tissue were used as bridges in two cases of obstetrical brachial plexus paralysis. RESULTS: By filling the vein lumen with small pieces of nerve tissue suspended in a heparinized saline solution, a potential problem associated with vein collapse caused by compression was solved. CONCLUSION: The authors suggest that tubulization techniques should be kept in mind in clinical practice when autologous nerve grafts are insufficient for distal target connectivity or as an alternative to conventional nerve grafts for bridging certain nerve defects.

Research on the possibility of overcoming traumatic paraplegia and its first clinical results.

The interruption of the continuity of the spinal cord is still an incurable lesion. In contrast with the peripheral nerves, the axons regenerating from the mother cells of the brain do not progress inside the cord. The reasons of this "non-permissiveness" are still unclear. This article describes the attempts of the author to overcome this non-permissiveness by means of a research that began in 1980 on rats, and continued since 1993 on monkeys. Results of the research on experimental animals were good and convincing so that this operation has been performed on fully informed human being volunteers affected by total severance of the cord between T8 and T11. Results of the first clinical cases are presented regarding operations performed either by rerouting the ulnar nerve to the lower limbs, or connecting the rostral stump of the severed cord with peripheral nerves of the hip to obtain rudimentary, but efficient, walking. Recovery occurred well in advance of the expected time, and continued to improve up to allow the first patient operated on by connecting CNS with PNS to walk with sticks after having walked for some months with a walker. This connection functioned even if the axons activating the single muscles were from mother cells dispersed in different regions of the brain cortex. These cells fire together giving selective contraction of diverse muscles. Furthermore, function occurred although the upper motor neuron uses the neurotransmitter glutamate, whereas motor end plates use receptors for acetylcholine. These data are under further investigation to determine whether the upper motor neuron changes the transmitter, or if the motor end changes its receptors (as seems to be by the first results).

Neuroprotective strategies in radical prostatectomy.

In this section, authors from New York give their views on the various neuroprotective strategies for patients having a radical prostatectomy, such as the use of nerve grafts and other approaches. A joint study from Korea, the USA, Canada and the UK is presented in a paper on the importance of patient perception in the clinical assessment and management of BPH. There is also a review of robotic urological surgery. Finally, authors from New York give a review on the life of Isaac Newton. This is a new historical review in the journal, but one that will be of general interest.

Making paraplegics walk again.

After attempting various types of research performed in different laboratories, this article describes the author's research that began in 1980 on rats, and continued since 1993 on monkeys. Also presented are results of the first clinical cases regarding operations performed either by rerouting the ulnar nerve to the lower limbs, or connecting the rostral stump of the severed cord with peripheral nerves of the hip to obtain rudimentary, but efficient, walking. Recovery occurred well in advance of the expected time, and continues to improve daily. This connection functioned even if the axons that activated the single muscles were from mother cells dispersed in different regions of the brain cortex, which fire together--such as in a teleassembly. Furthermore, function occurred although the upper motorneuron uses the neurotransmitter glutamate, whereas motor end plates use receptors for Acetilcholine. These data are under new investigation to determine whether the upper motorneuron changes the transmitter, or if the motor end plate changes its receptors.

The intercostal to phrenic nerve transfer: an effective means of reanimating the diaphragm in patients with high cervical spine injury.

Nerve transfers have been well described for the treatment of congenital and traumatic injuries in the brachial plexus and extremities. This series is the first to describe nerve transfers to reanimate the diaphragm in patients confined to long-term positive pressure ventilation because of high cervical spine injury. Patients who have sustained injury to the spinal cord at the C3 to C5 level suffer axonal loss in the phrenic nerve. They can neither propagate a nerve stimulus nor respond to implanted diaphragmatic pacing devices (electrophrenic respiration). Ten nerve transfers were performed in six patients who met these conditions. The procedures used end-to-end anastomoses from the fourth intercostal to the phrenic nerve approximately 5 cm above the diaphragm. A phrenic nerve pacemaker was implanted as part of the procedure and was placed distal to the anastomosis. Each week, the pacemaker was activated to test for diaphragmatic response. Once diaphragm movement was documented, diaphragmatic pacing was instituted. Eight of the 10 transfers have had more than 3 months to allow for axonal regeneration. Of these, all eight achieved successful diaphragmatic pacing (100 percent). The average interval from surgery to diaphragm response to electrical stimulation was 9 months. All patients were able to tolerate diaphragmatic pacing as an alternative to positive pressure ventilation, as judged by end tidal CO2 values, tidal volumes, and patient comfort. Intercostal to phrenic nerve transfer with diaphragmatic pacing is a viable means of liberating patients with high cervical spine injury from long-term mechanical ventilation.

Experimental model of pudendal nerve innervation of a skeletal muscle neosphincter for faecal incontinence.

BACKGROUND: Faecal incontinence is difficult to treat. A variety of reconstructive procedures has been described, but none is entirely satisfactory. This study evaluated the feasibility of cross-innervating a skeletal muscle neosphincter with the pudendal nerve in a canine model. METHODS: Thirty dogs were rendered surgically incontinent (the pudendal nerve was cut and the external sphincter was partially excised). A neosphincter was then created using the semitendinosus muscle. In ten dogs pudendal nerve transposition (PNT) to the nerve to the semitendinosus muscle was performed. Ten dogs were given a dynamic neosphincter by inserting a pulse generator at 6 weeks. The remaining ten dogs served as controls with passive semitendinosus wraps. Anal manometry was performed before operation and monthly for 5 months. Muscle biopsies, performed at the initial operation and at 5 months, were stained for slow- and fast-twitch fibres, and were examined histologically. RESULTS: At 1 month, mean sphincter function was 32 per cent of the preoperative value in the control animals, 34 per cent in the PNT group and 27 per cent in the electrostimulation group; all dogs were incontinent. At 5 months the mean recovery of sphincter function was 42 per cent of the preoperative value in controls, 100 per cent in dogs with PNT (P < 0.001) and 63 per cent in dogs having electrostimulation (stimulator on) (P = 0.02). Six dogs with PNT had squeeze pressures equal to or greater than preoperative levels. At 5 months the ratio of slow to fast fibres was significantly greater in all dogs (control P = 0.01, PNT P < 0.005, electrostimulation P < 0.001). CONCLUSION: Use of the pudendal nerve to innervate a canine skeletal muscle anal wrap produced a functional anal sphincter that was superior to electrically stimulated and passive wraps.