Schwannoma de nervio facial con reanimación facial con Neurotizacion Hipoglosofacial / SCHWANNOMA OF THE FACIAL NERVE WITH FACIAL RESUSCITATION WITH FACIAL HYPOGLOSSAL NEUROTIZATION

El schwannoma es una patología rara del nervio facial. Su diagnóstico preoperatorio es dificultoso dado que no tiene síntomas ni signos patognomónico de la enfermedad. La disección del nervio facial en su tronco y sus ramas con electroestimulacion es la forma de quirúrgica de sospecharlo intraoperatoriamente. La descompresión parcial o exeresis completa deberá ser considerado de acuerdo a la experiencia del equipo quirúrgico en reconstrucción nerviosa. La reparación del nervio facial como primera opción debe el injerto inmediato o sutura termino terminal. La neurotización es un procedimiento quirúrgico que le provoca al paciente simetría facial con manejo de oclusión ocular y manejo de comisura bucal, debe ser realizado antes del año de la injuria nerviosa. La rehabilitación del nervio facial necesita de un equipo multidisciplinario y la colaboración permanente del paciente para conseguir los objetivos propuestos.

Schwannoma is a rare pathology of the facial nerve. Its preoperative diagnosis is difficult since it has no symptoms or pathognomonic signs of the disease. The dissection of the facial nerve in its trunk and its branches with electrostimulation is the surgical way to suspect it intraoperatively. Partial decompression or complete exeresis should be considered according to the experience of the surgical team in nerve reconstruction. The repair of the facial nerve as a first option should be the immediate graft or end-to-end suture. Neurotization is a surgical procedure that causes the patient facial symmetry with management of ocular occlusion and management of the corner of the mouth, it must be performed within a year of the nerve injury. The rehabilitation of the facial nerve requires a multidisciplinary team and the permanent collaboration of the patient to achieve the proposed objectives.

Masseteric-Facial Anastomosis: A Report of Three Cases

Intoduction The pathways of the facial nerve are variable, and knowledge of that is essential. The worst impact caused by facial paralysis is related to quality of life, especially regarding the self-esteem and social acceptance on the part of the patients, leading to social isolation and disruption on their mental health. Case Report A 33-year-old female patient, with a stage-T3 acoustic neurinoma, presented with a moderate dysfunction (grades II to III) according to the House- Brackmann (HB) Facial Nerve Grading System. A 43-year-old male patient, with a stage- T4B trigeminal schwannoma, underwent a resective surgery and presented grade-VI dysfunction according to the HB scale. And a female patient with a stage-T4A acoustic neurinoma presented grade-IV dysfunction according to the HB scale. Discussion We performed a literature review of papers related to surgeries for masseteric-facial nerve anastomosis and compiled the results in table; then, we compared these data with those obtained from our cases. Conclusion The masseteric nerve is the one that shows the best prognosis among all the cranial nerves that could be used, but it is also necessary to perform well the surgical technique to access the facial branch and consequently achieve a better masseteric-facial nerve anastomosis.

Impacts of Rehabilitation Gait Training on Functional Outcomes after Tibial Nerve Transfer for Patients with Peroneal Nerve Injury: A Nonrandomized Controlled Trial.

BACKGROUND: Although there was initial success using tibial nerve transfer to restore ankle dorsiflexion following peroneal nerve injury, results from later series were less promising. A potential reason is coactivation of the much stronger antagonistic muscles during gait. The purpose of this study was to test the hypothesis that gait training would improve functional performance following tibial nerve transfer. METHODS: Using a prospective, nonrandomized, controlled study design, patients were divided into two groups: surgery only or surgery plus gait training. Of the 20 patients who showed reinnervation in the tibialis anterior muscle, 10 were assigned to the gait training group, and an equal number were in the control group. Those in the treatment group began training once reinnervation in the tibialis anterior muscle was detected, whereas those in the control group continued to use their ankle-foot orthosis full time. Differences in ankle dorsiflexion were measured using the Medical Research Council scale, and quantitative force measurement and functional disability was measured using the Stanmore Scale. RESULTS: Patients in the gait training group attained significantly better functional recovery as measured by the Stanmore Scale (79.5 ± 14.3) (mean ± SD) versus (37.2 ± 3.5) in the control group (p = 0.02). Medical Research Council grades were 3.8 ± 0.6 in the training group versus 2.5 ± 1.2 in the surgery only group (p < 0.05). Average dorsiflexion force from patients with above antigravity strength (all from the training group) was 31 percent of the contralateral side. CONCLUSION: In patients with successful reinnervation following tibial nerve transfers, rehabilitation training significantly improved dorsiflexion strength and function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Management of large peripheral nerve defects with autografting.

INTRODUCTION: A segmental nerve defect from trauma results in significant loss of function of the extremity, and rarely occurs in isolation. Autografting of the nerve defect is the current gold standard. METHODS: A review of the recent literature regarding peripheral nerve defects after trauma treated with autograft. RESULTS: Identification of the zone of nerve injury is difficult and appropriate resection is critical for good outcomes. Meaningful recovery is more likely with application of excellent technique. Many of the factors affecting outcomes are not modifiable. CONCLUSION: Nerve grafting for segmental nerve injuries continues to be an essential and appropriate treatment.

Outcomes, Challenges, and Pitfalls after Targeted Muscle Reinnervation in High-Level Amputees: Is It Worth the Effort?

BACKGROUND: Although the distal targets have been lost in proximal upper limb amputees, the neural signals for intuitive hand and arm function are still available and thus can be incorporated into more useful prosthetic function using targeted muscle reinnervation technique. In this article, the authors present their outcomes and range of indications in addition to experiences and pitfalls after 30 targeted muscle reinnervation cases at above-elbow and shoulder disarticulation level of amputation. METHODS: Thirty patients with above-elbow or shoulder disarticulation amputations were enrolled between 2012 and 2017. Indications for targeted muscle reinnervation surgery differed between improvement of prosthetic function (n = 19) and/or pain (n = 11). Functional outcome was evaluated with the Action Research Arm Test, the Southampton Hand Assessment Procedure, and the Clothespin-Relocation Test. Functional evaluation was performed at least at 6 months after final prosthetic fitting. RESULTS: All nerve transfers were successful and provided independent myoelectric signals. The 10 patients available for final functional evaluation showed Action Research Arm Test scores of 20.4 ± 1.9 and Southampton Hand Assessment Procedure scores of 40.5 ± 8.1. The Clothespin-Relocation Test showed a mean time of 34.3 ± 14.4 seconds. CONCLUSIONS: Targeted muscle reinnervation has improved prosthetic control and revolutionized neuroma treatment in upper limb amputees. Still, the rate of abandonment even after targeted muscle reinnervation surgery has been shown high, and several advances within the biotechnological interface will be needed to improve prosthetic function and acceptance in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Structured Motor Rehabilitation After Selective Nerve Transfers.

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning. Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

Restoration of Elbow Flexion in Traumatic Upper Brachial Plexus Palsy in Adults: Outcome with Intraplexus Distal Nerve Transfers in 78 Patients

Objective To present the functional outcomes of distal nerve transfer techniques for restoration of elbow flexion after upper brachial plexus injury. Method The files of 78 adult patients with C5, C6, C7 lesions were reviewed. The attempt to restore elbow flexion was made by intraplexus distal nerve transfers using a fascicle of the ulnar nerve (group A, n » 43), or a fascicle of themedian nerve (group B, n » 16) or a combination of both (group C, n » 19). The result of the treatment was defined based on the British Medical Research Council grading system: muscle strength < M3 was considered a poor result. Results The global incidence of good/excellent results with these nerve transfers was 80.7%, and for different surgical techniques (groups A, B, C), it was 86%, 56.2% and 100% respectively. Patients submitted to ulnar nerve transfer or double transfer (ulnar þ median fascicles transfer) had a better outcome than those submitted to median nerve transfer alone (p < 0.05). There was no significant difference between the outcome of ulnar transfer and double transfer. Conclusion In cases of traumatic injury of the upper brachial plexus, good and excelent results in the restoration of elbow flexion can be obtained using distal nerve transfers.

Nerve Transfer Surgery for Penetrating Upper Extremity Injuries.

CONTEXT: Nerve transfer surgery is an option for repair of penetrating injuries of the upper extremity. In the right setting, it has advantages over tendon transfers and nerve grafting. OBJECTIVE: To review our experience since 2006 of nerve transfer surgery in the upper extremities. DESIGN: We included cases performed to repair penetrating trauma within three months of injury with at least three years' follow-up. MAIN OUTCOME MEASURES: Preoperative and postoperative muscle strength of the affected extremity. RESULTS: All 16 patients were males aged 16 to 43 years. Six patients underwent nerve transfer surgery because of elbow flexion; 5, finger extension; 3, finger flexion; and 2, wrist pronation. Nine patients (56%) had associated vascular injury, and 4 (25%) had fractures. Average follow-up was 6 years. No perioperative complications occurred. Patients had a mean of 3.7 operations after the initial trauma. All patients received physical therapy. All patients improved from 0 of 5 muscle strength preoperatively to a mean of 3.8 (range = 2/5 to 5/5) within 1 year after surgery. In all cases, strength was maintained, and 8 (50%) had continued improvement after Year 1. Ten (63%) returned to their previous employment level. Mean Disabilities of the Arm, Shoulder and Hand score improved from 68 to 83 postoperatively. CONCLUSION: Nerve transfer is a safe, effective technique for correcting penetrating trauma-related nerve injury. In appropriate patients it offers advantages over other techniques. Outcomes can be maintained long term, and many patients can return to their previous level of function.

Reflex-based grasping, skilled forelimb reaching, and electrodiagnostic evaluation for comprehensive analysis of functional recovery-The 7-mm rat median nerve gap repair model revisited.

INTRODUCTION: The rat median nerve injury and repair model gets increasingly important for research on novel bioartificial nerve grafts. It allows follow-up evaluation of the recovery of the forepaw functional ability with several sensitive techniques. The reflex-based grasping test, the skilled forelimb reaching staircase test, as well as electrodiagnostic recordings have been described useful in this context. Currently, no standard values exist, however, for comparison or comprehensive correlation of results obtained in each of the three methods after nerve gap repair in adult rats. METHODS: Here, we bilaterally reconstructed 7-mm median nerve gaps with autologous nerve grafts (ANG) or autologous muscle-in-vein grafts (MVG), respectively. During 8 and 12 weeks of observation, functional recovery of each paw was separately monitored using the grasping test (weekly), the staircase test, and noninvasive electrophysiological recordings from the thenar muscles (both every 4 weeks). Evaluation was completed by histomorphometrical analyses at 8 and 12 weeks postsurgery. RESULTS: The comprehensive evaluation detected a significant difference in the recovery of forepaw functional motor ability between the ANG and MVG groups. The correlation between the different functional tests evaluated precisely displayed the recovery of distinct levels of forepaw functional ability over time. CONCLUSION: Thus, this multimodal evaluation model represents a valuable preclinical model for peripheral nerve reconstruction approaches.

Rehabilitation of Supinator Nerve to Posterior Interosseous Nerve Transfer in Individuals With Tetraplegia.

Despite being a routine part of the early surgical management of brachial plexus injury, nerve transfers have only recently been used as a reconstructive option for those with tetraplegia. Subsequently, there is limited published literature on the rehabilitation theories and techniques for optimizing outcomes in this population. This article seeks to address this void by presenting our centers' working model for rehabilitation after nerve transfers for individuals with tetraplegia. The model is illustrated with the example of the rehabilitation process after a supinator nerve to posterior interosseous nerve transfer. This nerve transfer reconstructs wrist, finger, and thumb extension. The topics covered in the model include the following: patient selection and presurgical planning/intervention, managing the postoperative healing phase of an individual who is wheelchair dependent, maximizing motor reeducation, increasing muscle strength, and ensuring use in functional tasks. This article provides a platform for further development and collaboration to improve the outcomes of patients who undergo nerve transfers after tetraplegia.

Donor Distal, Recipient Proximal and Other Personal Perspectives on Nerve Transfers.

This article presents a personal overview of nerve transfers and emphasizes the various factors that contribute to outcome following these surgeries. There is no "one result" for all nerve transfers. The results will vary depending on factors relating to the donor nerve and the recipient nerve, the degree of the surgical difficulty of the specific procedure, and issues relating to preoperative and postoperative rehabilitation. The general issues that influence all nerve injury and recovery, such as age of the patient, comorbidities, and time since injury, pertain to nerve transfers as well.

Nerve Transfers to Restore Shoulder Function.

The restoration of shoulder function after brachial plexus injury represents a significant challenge facing the peripheral nerve surgeons. This is owing to a combination of the complex biomechanics of the shoulder girdle, the multitude of muscles and nerves that could be potentially injured, and a limited number of donor options. In general, nerve transfer is favored over tendon transfer, because the biomechanics of the musculotendinous units are not altered. This article summarizes the surgical techniques and clinical results of nerve transfers for restoration of shoulder function.

High Median Nerve Injury: Motor and Sensory Nerve Transfers to Restore Function.

This article describes the clinically significant motor and sensory deficits that follow high median nerve injuries and addresses the indications, limitations, and outcomes of nerve transfers, when striving to overcome the deficits these patients' experiences. Preferred surgical reconstructive strategy using motor and sensory nerve transfers, and surgical techniques used to perform these transfers, are described.

High Ulnar Nerve Injuries: Nerve Transfers to Restore Function.

Peripheral nerve injuries are challenging problems. Nerve transfers are one of many options available to surgeons caring for these patients, although they do not replace tendon transfers, nerve graft, or primary repair in all patients. Distal nerve transfers for the treatment of high ulnar nerve injuries allow for a shorter reinnervation period and improved ulnar intrinsic recovery, which are critical to function of the hand.

Donor Activation Focused Rehabilitation Approach: Maximizing Outcomes After Nerve Transfers.

As nerve transfers become the mainstay in treatment of brachial plexus and isolated nerve injuries, the preoperative and postoperative therapy performed to restore motor function requires continued dedication and appreciation. Through the understanding of the general principles of muscle activation and patient education, the therapist has a unique impact on the return of function in patients with nerve injuries. As surgeons continue to develop novel nerve transfers, the perioperative training, education, and implementation of the donor activation focused rehabilitation approach model is critical to ensure successful outcomes.

Nerve Transfers in the Upper Extremity: A Practical User's Guide.

Nerve injuries above the elbow are associated with a poor prognosis, even with prompt repair and appropriate rehabilitation. The past 2 decades have seen the development of numerous nerve transfer techniques, by which a denervated peripheral target is reinnervated by a healthy donor nerve. Nerve transfers are indicated in proximal brachial plexus injuries where grafting is not possible or in proximal injuries of peripheral nerves with long reinnervation distances. Nerve transfers represent a revolution in peripheral nerve surgery and offer the potential for superior functional recovery in severe nerve injuries. However, the techniques have not been universally adopted due in part to a misconception that nerve transfers can only be understood and performed by superspecialists. Nerve transfer procedures are not technically difficult and require no specialized equipment. Numerous transfers have been described, but there are a handful of transfers for which there is strong clinical evidence. To restore shoulder abduction and external rotation in upper trunk brachial plexus injury, the key transfers are the spinal accessory to suprascapular nerve and the medial triceps branch to axillary nerve. For elbow flexion, the flexor carpi ulnaris branch of ulnar nerve to the biceps and brachialis branches of the musculocutaneous nerve is the key transfer. For ulnar intrinsic function, the distal anterior interosseous nerve to ulnar motor branch transfer has yielded excellent functional results. Nerve transfers form a therapeutic triad with traditional tendon transfers and functional motor unit rehabilitation which, when applied appropriately, can yield excellent functional results in complex nerve injuries. Nerve transfers are a powerful yet underused tool for proximal nerve injuries, which offer hope for traditionally discouraging injuries.

Advances in nerve transfer surgery.

Peripheral nerve injuries are devastating injuries and can result in physical impairments, poor functional outcomes and high levels of disability. Advances in our understanding of peripheral nerve regeneration and nerve topography have lead to the development of nerve transfers to restore function. Over the past two decades, nerve transfers have been performed and modified. With the advancements in surgical management and recognition of importance of cortical plasticity, motor-reeducation and perioperative rehabilitation, nerve transfers are producing improved functional outcomes in patients with nerve injuries. This manuscript explores the recent literature as it relates to current nerve transfer techniques and advances in post-operative rehabilitation protocols, with a focus on indications, techniques and outcomes.

Nerve transfers.

Nerve transfers have been performed for many years, but the technique is further developing and gaining increased recognition as a time-tested procedure. The original operations are continually modified to treat a wide variety of peripheral nerve injuries, and yield reliable results. In addition, nerve transfers can be used in conjunction with tendon transfers or nerve grafts in order to best treat a specific patient's set of deficits. This review of nerve transfers briefly discusses the evolution of the technique, general principles, some specific transfers, post-operative rehabilitation, and their place on the reconstructive ladder.

Nerve transfers. New options for reconstruction following nerve injury.

Surgical reconstruction of proximal level nerve repair or long nerve grafts have provided less than optimal results, presenting the opportunity for investigation of alternate reconstructive techniques. Good motor function following an injury to a motor nerve requires a maximal number of motor axons reaching the motor end plate within a critical time period. Nerve transfers eliminate the need for a nerve graft by allowing a direct end to end nerve repair without tension. This article reviews surgical options using nerve transfers for patients with upper and lower extremity nerve injuries.

Direct muscular neurotization as a method of treatment of irreparable nerve injuries.

Authors have presented of 12 patients with irreparable nerve injuries treated by direct motor nerve implantation into muscle belly (direct muscular neurotization). Results were evaluated in Sunderland scale. Motor function of the neurotized muscles following 12 months from operation was in range of between M3 and M4.