Spinal accessory to suprascapular nerve transfer in brachial plexus injury: outcomes of anterior vs. posterior approach to the suprascapular nerve at associated ipsilateral spinal accessory nerve injury

Objective: The spinal accessory nerve (Acc) is susceptible to trauma in at least 6% of cases of brachial plexus injury (BPI). The impaired Acc function disables its utilization for transfer to the suprascapular nerve (SS). The selection of approach to SS is highly dependant on the anatomy of BPI. The purpose of this study was to determine the incidence of the anterior-posterior approach of Acc to SS transfer in BPI and associated functional outcomes. Methods. Twenty nine patients with BP/Acc associated injury were included. Ten patients underwent the transfer of Acc to SS by the anterior approach (AA), 19 patients – by the posterior approach (PA). Nine nerve transfers through AA and one nerve transfer through PA required the interposition of an autologous nerve graft. The functioning of the supra-/infraspinatus muscle was evaluated at 9 and 15mos. on the basis of the MRC and the external rotation (ER) range. ER more than +400 beyond the sagittal plane was regarded as effective recovery of function. Results. Impaired function (M3 or lower on MRC) of the lower trapezius muscle was associated with preserved anatomy of the SS in the supraclavicular region in 9 out of 10 cases. Eighteen patients (62%) recovered to M3 and higher (shoulder stability), 11of these (38%) showed recovery to M4-M5. Five of all patients recovered to M4-M5 and were able to produce ER within the effective ROM (+400-600 of ER). After the AA to the SS, shoulder stability was restored in 60% of cases (M4-M5 in 30%). After the PA to the SS, shoulder stability was restored in 74% of cases (M4-M5 in 42%). Only non-complete BPI showed effective recovery of power and function in terms of less than 6 mos. after injury. PA to SS with no graft provided shoulder stability in 72% of cases, AA to the SS and the graft interposition ensured shoulder stability in 50% of cases. Conclusions. The incidence of AA to the SS was 35%, PA – 65%; preserved anatomy of the SS in supraclavicular region was associated with an increased risk of trapezius muscle dysfunction; the PA to SS and consecutive direct end-to-end transfer of Acc showed better results compared to other combinations of nerve transfers in providing shoulder stability

A Funhouse Mirror: Muscular Co-Contractions as a Reflection of a Spontaneous Aberrant Regeneration of the Brachial Plexus Injury in the Adults - Anatomical Background, an Attempt to Classify and Their Clinical Relevance within the Reconstruction Strategie

A certain number of spontaneously recovering birth injuries to the brachial (BPI) plexus are known to be accompanied by muscle co-contractions (Co-Cs). The process of aberrant spontaneous regeneration contributes to the appearance of this phenomenon. Treatment strategies are mostly narrowed down to temporarily “switching off” the antagonist, allowing the agonist to perform. Less is known about the incidence of BPI-associated Co-Cs in adults (a-BPI), the control of which mainly presumes the extrapolation of a treatment strategy that has been shown to be effective in infants. Nowadays, surgical reconstruction of independent elbow flexion at BPIs relies heavily on redirection (transfer) of nerves that produce their own Co-Cs. These induced Co-Cs could potentially be reduced. Selecting the appropriate nerve transfer strategy (when the donor pool is narrowing), with its potential impact on the already complex and intricate global and segmental biomechanics of the upper extremity, becomes challenging. The chapter presents the anatomical background for the occurrence of muscular Co-Cs, a work on clinical classification of both regeneration associated and induced Co-Cs, possible surgical strategies, their benefits and limitations, in the presence of regeneration-associated muscle Co-Cs at a-BPI and clinical examples

Невротизація заднього міжкісткового нерва при проксимальних ушкодженнях променевого нерва для відновлення незалежної функції розгиначів пальців кисті

Background. Reconstruction of proximal radial nerve (RN) injuries via grafting technique brings good recovery of wrist extensors, wherein finger and thumb extensors recover to a lesser degree. The outcomes are strongly dependent on a gap length, timing of procedure, etc. An alternative approach — median (MN) to RN transfer — brings regenerating axons much closer to target muscles.Objective. To compare the recovery of wrist and finger extensors provided by grafting versus distal neurotization technique at proximal RN injury.Methods. Twenty-eight patients with proximal RN injuries underwent 21 reconstruction of RN continuity via grafting technique. Seven patients underwent transfer of MN branches of m. flexor carpi radialis (FCR) and m. palmaris longus (PL) to n. posterior interosseus (PIN) with simultaneous transfer of m. pronator teres (PT) to m. extensor carpi radialis brevis (ECRB).Results. RN grafting brought recovery of the entire complex of thumb, fingers and wrist extensors only in 10 out of 21 cases (47.6 %). Radial wrist extensor(s) recovered in 100 % of cases, thumb extensors — in 85.7 %, finger extensors recovered in 61.9 % patients, with only 47.6 % showed recovery of thumb abductors. Eight patients required additional tendon transfers to restore fingers extension, 3 persons required thumb extension, 11 patients required thumb abduction. All 7 patients (100 %) after MN to PIN transfer received powerful and independent finger and thumb extension, as well as thumb abduction in much earlier terms. PT to ECRB transfer provided powerful and early wrist extension.Conclusions. The outcomes of MN to RN transfer at proximal RN injuries are more predictable, cogent and time-saving compared to the outcomes received with grafting in terms of recovery of full-fledged function of fingers extensors and thumb abductors.Вступление. Восстановление лучевого нерва при его проксимальных повреждениях методом аутологической нейропластики позволяет достичь удовлетворительной функции разгибателей кисти. Однако восстановление функции разгибателей пальцев не всегда достигает приемлимых показателей. Результаты восстановления в значительной степени зависят от размера дефекта лучевого нерва, срока проведения реконструктивного вмешательства и т.д. Алтернативная методика (невротизация заднего межкосного нерва ветками срединного нерва на предплечьи) существенно приближает регенерирующие аксоны к целевой мускулатуре предплечья.Цель: сравнить результаты восстановления функции разгибателей кисти и пальцев при реконструкции проксимальных повреждений лучевого нерва методом аутологической нейропластики и дистальной невротизации заднего межкостного нерва.Материалы и методы. Реконструкцию анатомической целосности лучевого нерва методом аутологической нейропластики проведено 21 пациенту, невротизацию заднего межкостного нерва ветками срединного нерва к лучевому сгибателю кисти и длинной мышце, напрягающей ладонный апоневроз, на предплечьи – 7.Результаты. Аутологическая нейропластика позволила достичь восстановления всего комплекса разгибателей пальцев в 10 (47,6%) случаях. Восстановление функции лучевых разгибателей кисти произошло в в 100% случав, мышц, разгибающих фаланги пальцев, – в 85,7%, общих разгибаталей пальцев – в 61,9%, полноценное восстановление мышц, отводящих 1-й палец, – в 47,6% случаев. В отдаленные сроки и 8 пациентам проведено реконструктивные вмешательства на сухожильно-мышечном аппарате для восстановления функции разгибателей пальцев, 3 – для восстановления разгибания фаланг 1-го пальца, 11 – для восстановления отведения 1-го пальца. У всех пациентов после невротизации заднего межкостного нерва ветками срединного нерва достигнуто удовлетварительное восстановление функции разгибателей пальцев, отведения 1-го пальца в значительно более короткие сроки. Транспозиция мышцы круглого пронатора предплечья на короткий лучевой разгибатель кисти обеспечила эффективное раннее восстановление разгибания в лучезапястном суставе.Выводы. Результаты невротизации заднего межкостного нерва ветками срединного нерва более предсказуемы, надежны, восстановление происходит в более ранние термины по сравнению с аутологической нейропластикой при проксимальных повреждениях лучевого нерва.Вступ. Відновлення променевого нерва при його проксимальних ушкодженнях шляхом автологічної пластики дає змогу досягти задовільної функції розгиначів кисті. Однак відновлення функції розгиначів пальців не завжди досягає прийнятних показників. Результати відновлення значною мірою залежать від розміру дефекту променевого нерва, терміну проведення реконструктивного втручання тощо. Альтернативна методика (невротизація заднього міжкісткового нерва гілками серединного на передпліччі) значно наближує аксони, які регенерують, до цільової мускулатури передпліччя.Мета: порівняти результати відновлення функції розгиначів кисті та пальців при реконструкції проксимальних ушкоджень променевого нерва методом автологічної нервової пластики та дистальної невротизації заднього міжкісткового нерва.Матеріали і методи. Реконструкцію анатомічної цілісності променевого нерва методом автологічної нервової пластики проведено 21 пацієнтам, невротизацію заднього міжкісткового нерва гілками серединного нерва до променевого згинача кисті та довгого м’яза, який напружує долонний апоневроз, на передпліччі – 7.Результати. Автологічна нервова пластика дала змогу досягти відновлення всього комплексу розгиначів пальців лише у 10 (47,6%) пацієнтів. Відновлення функції променевих розгиначів кисті відбулося у 100% випадків, м’язів, які розгинають фаланги 1-го пальця, – у 85,7%, загальних розгиначів пальців – у 61,9%, повноцінне відновлення м’язів, котрі відводять 1-й палець, – у 47,6%. У віддалені терміни 8 пацієнтам проведено реконструктивні втручання на сухожилково-м’язовому апараті для відновлення функції розгиначів пальців, 3 – для відновлення розгинання фаланг 1-го пальця, 11 – для відновлення відведення 1-го пальця. В усіх пацієнтів після невротизації заднього міжкісткового нерва гілками серединного нерва досягнуто задовільного відновлення функції розгиначів пальців, відведення 1-го пальця в значно коротші терміни. Транспозиція м’яза круглого пронатора передпліччя на короткий променевий розгинач кисті забезпечила потужне раннє відновлення функції розгинання в променево-зап’ястковому суглобі.Висновки. Результати невротизації заднього міжкісткового нерва гілками серединного нерва більш передбачувані, надійні, відновлення відбувається в раніші строки порівняно з автологічною нервовою пластикою при проксимальних ушкодженнях променевого нерва

Selective surgical reinnervationn of the axillary nerve due to supraclavicular brachial plexus injury: outcomes of 42 consecutive cases, causes of inefficacy

Objective: retrospective analysis of the outcomes of selective surgical reinnervation (SSR) of the axillary nerve (Ax) in patients with supraclavicular brachial plexus injury (SBPI). Materials and methods. Forty-two patients (mean age 31.2 years) received 25 SSR with extraplexus donor nerves (e-ND) – 9 cases of subtotal SBPI and 16 cases of complete SBPI. In 17 cases of subtotal SBPI exclusively intraplexus donor nerve (i-ND) were utilized. Twenty-nine (69%) patients received SSR in terms up to 6 months, 13 patients (31%) – in terms more than 6 months. All patients at the time of inclusion were examined neurologically, electophisilogically and in 6, 9, 15 and 17 months. Recovery of the deltoid (D) muscle was assessed on Medical Research Council Scale (MRC Scale) – effective power (Еp). Recovery of effective function (Ef) has been assessed on the basis of flexion angle in glenohumeral joint in sagittal plane. Results. Ер of D recovered in 12 patients (28%), in terms up to 6 months - in 31%, more than 6 months – in 23%. Ep of D recovered after SSR with i-ND in 9 patients (52%), in terms up to than 6 months - in 60%, more than 6 months – in 43%. Ep of D recovered after SSR with e-ND in 3 patients (12%), in terms up to 6 months- in 16%, no recovery of Ep has been observed in terms more than 6months.Ef of D recovered in 11 patients (26%), in terms up to 6months - in 31%, more than 6months – in 15%. Ef of D recovered after SSR with i-ND in 8 patients (53%), in terms up to 6 months - in 60%, more than 6 months – in 29%. Ep of D recovered after SSR with e-ND in 3 cases (12%), in terms up to 6months - in 16%, no recovery of Ep has been observed in terms more than 6months. Recovery of Ef of D at subtotal SBPI occurred in 10 cases (38%), regardless of whether i-ND or e-ND have been utilized. SSR with e-ND at subtotal SBPI allowed restoring Ef of D in 2 cases (22%). SSR with i-ND at subtotal SBPI allowed restoring Ef of D in 8 cases (47%). SSR at complete SBPI allowed restoring Ef of D in 1 case (6%). Conclusions. e-ND can be utilized at complete SBPI in order to provide stability to glenohumeral joint in terms up to 6 months; i-ND should be utilized in all cases of subtotal SBPI in order to provide Ef to D in terms up to 6 months

Redefining the Inclusion Criteria for Successful Steindler Flexorplasty Based on the Outcomes of a Case Series in Eight Patients

Background (rationale) Steindler flexorplasty (SF) is aimed at restoring independent elbow flexion in the late stages of dysfunction of the primary elbow flexors. Selection criteria for successful SF have been defined

Early and delayed surgical management of the pronator teres syndrome. Selective reinnervation of the anterior interosseous nerve aimed to restore pinch grip among patients with late clinical presentation

Background. The incidence of pronator teres syndrome (PTS) is low. The misdiagnosis leads to delay in surgical treatment and irreversible changes not only within the median nerve (MN) itself, but within the sensory and muscular apparatus as well.Objective: to compare the outcomes of early and delayed surgical management of PTS; to compare the restoration of the pinch grip (PG) after decompression and reinnervation (nerve transfer, NT) of the anterior interosseous nerve (AIN) vs. decompression of MN alone in late terms of the disease (PTS).Materials and Methods. Six patients with verified PTS were included into the study. Three patients with the history of the disease (HoD) less than 3 mos. received surgical decompression (SD) of MN under standartized methodology alone. Another three patients with the HoD more than 3 mos. received SD of MN, with two of them received simultaneous NT of the branches of the radial or MN to AIN. In all patients sensory and motor deficit (function of "extrinsic"and "intrinsic"muscles), intensity of the neuropathic pain, both pre- and post-surgery have been evaluated according to MRC Scale and VAS, respectively. An ability to reproduce PG, or “OK” sign, with help of the thumb (flexor pollicis longus muscle – FPL) and index finger (deep flexor muscle – FDP2) were evaluated.Results. All patients showed complete relief of the neuropathic pain (VAS0) regardless of the terms of the disease. Three patients with HoD less than 3 mos. showed good recovery of FPL, FDP2 (M4-5) – all patients were able to reproduce "OK" sign. One patient with HoD more than 3 mos. after SD of MN alone showed no recovery of FPL, FDP2 (M0-1). Another two patients with the HoD more than 3 mos. showed good recovery of FPL and FDP2 (M3-4) after NT to AIN. No patient with HoD more than 3 mos. was able to reproduce "OK" sign.Conclusions. Early decompression of MN in PTS cases results in complete relief of the sensory and motor neurologic deficit; late decompression of MN in PTS cases does not lead to relief of the sensory deficit within NCP autonomous area, while the prognosis of the recovery of the median nerve innervated “extrinsic” and “intrinsic” muscles is rather unfavorable; In case of late PTS presentation, NT to AIN allows restoring only a single component ("extrinsics") of the motor functions of the hand which are required for the succesfull reproduction of the pinch grip; In case of late PTS presentation, poor recovery of OP should be expected, hence the succesfull reproduction of the pinch grip due to the thumb hyperadduction would be impossible; carefull interpretation of the clinical, radiological and electophysiological data on the pre-surgical stage could potentially help avoiding the misdiagnosis and improve the outcomes of the surgical treatment in all cases of a single or multilevel MN entrapment

Changing the concept of surgical treatment of the brachial plexus traumatic injuries

Objective: the objective of this study was to retrospectively analyze the change in the surgical strategy (SS) of brachial plexus injuries (BPI), the outcomes of different SS and the factors that influenced the establishing process of a new SS in a single surgical centre in Kyiv, Ukraine. Materials and Methods. 148 patients (mean age 29.5) received 76 neurolysis (N), 14 grafting (G) and 58 nerve transfer (NT) surgeries after a mean 7.4 months following BPI. 29 patients received NT of n. phrenicus, 7 –ulnar nerve fascicles, 9 – lateral pectoral nerve, 7 – medial pectoral nerve to musculocutaneous nerve aimed to restore active elbow flexion. Six other patients received NT of ipsilateral extraplexal motor nerves. The follow-up period included neurological examination (MRC Scale), electromyographic examination and angular deviation in the elbow joint during recovered active elbow flexion. 148 patients were retrospectively divided into two groups A (102 patients, received surgeries from surgical team #1) and B (46 patients, received surgeries from surgical team #2). The SS used in each group and its change with time was analyzed during the 6-year span. Results. 41 patients (70.7%) showed recovery of effective power (Ep) (M4-5) of biceps brachii muscle (BB) after NT. 14 patients (18.4%) showed recovery of Ep of BB after N. 4 patients (28.6%) showed recovery of Ep of BB after G. Overall Group A patients received 55 NT, Group B – 3 NT. The number of NT among Group A patients increased in 2013-2019 from 31% to 100% with overall efficacy of NT increased from 50% to 83%. Conclusions. SS of BPI changed only for Group A patients – N was completely replaced by NT in 2019. For Group B patients N remained SS of choice. The establishing of new SS was influenced by four factors (time, anatomy of injury, donor nerves, radiological findings). The factors being processed, allowed us to define optimal time, effective donors and non-reliability of radiology at BPI. We state that it is only matter of own experience, based on the thorough analysis of the technique, that brings positive outcomes after new SS has been adopted

The choice of method of electroneuromyogaphy in remote consequences of gunshot and mine-blast injuries of limb nerves

Objective. Clarification of the nature of damage and degree of functional disorders in the remote consequences of gunshot and mine-blast injuries of limb nerves using neurophysiological techniques (NP) of functional diagnostics (stimulation and needle electromyography), correlation of these data with the nerve damage characteristics determined during surgical interventions (operative findings). Materials and methods. 480 military personnel and civilians, men aged 18-64 years (average age 33.5 years), with gunshot and mine-blast injuries of limb nerves (LNI) within 1 to 11 months after injury were examined. A total of 1400 EMG studies were conducted. Clinical-neurological methods were used to determine the level, degree, and nature of LNI. Results. Among the examined 480 patients, complete nerve damage was detected in 299, and partial in 181. Causes of nerve damage included: shrapnel, gunshot, mine-blast injuries, nerve rupture due to bone fractures, injuries by sharp objects, iatrogenic damage. In 62.3% of cases of complete LNI surgical interventions were performed using the technique of neurotization using branches of donor nerves. Provided anatomical integrity of nerve structures and presence of conductivity during EMG testing, external or internal neurolysis was performed. Surgical intervention timing: up to 6 months post-injury - 68.1% of cases; up to 3 months - 31.9%. Based on the results of comprehensive clinical-NP research, adapted schemes for assessing NP data corresponding to each pathohistological type of LNI were developed, and NP criteria for classifying consequences of LNI into three degrees of severity of functional deficit - mild, moderate, and severe were proposed. Conclusions. Criteria for choosing the optimal NP diagnostic methodology for the remote consequences of gunshot and mine-blast injuries of limb nerves have been determined. Comprehensive clinical-instrumental diagnostics allows to objectify the level and degree of limb nerve damage, signs of neuromuscular apparatus recovery, provides information for planning of the surgical tactics and subsequent rehabilitation therapy