Future Perspectives in the Management of Nerve Injuries

Aim The author presents a solicited “white paper” outlining her perspective on the role of nerve transfers in the management of nerve injuries. Methods PubMed/MEDLINE and EMBASE databases were evaluated to compare nerve graft and nerve transfer. An evaluation of the scientific literature by review of index articles was also performed to compare the number of overall clinical publications of nerve repair, nerve graft, and nerve transfer. Finally, a survey regarding the prevalence of nerve transfer surgery was administrated to the World Society of Reconstructive Microsurgery (WSRM) results. Results Both nerve graft and transfer can generate functional results and the relative success of graft versus transfer depended on the function to be restored and the specific transfers used. Beginning in the early 1990s, there has been a rapid increase from baseline of nerve transfer publications such that clinical nerve transfer publication now exceeds those of nerve repair or nerve graft. Sixty-two responses were received from WSRM membership. These surgeons reported their frequency of “usually or always using nerve transfers for repairing brachial plexus injuries as 68%, radial nerves as 27%, median as 25%, and ulnar as 33%. They reported using nerve transfers” sometimes for brachial plexus 18%, radial nerve 30%, median nerve 34%, ulnar nerve 35%. Conclusion Taken together this evidence suggests that nerve transfers do offer an alternative technique along with tendon transfers, nerve repair, and nerve grafts.

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Distal Nerve Transfers: A Perspective on the Future of Reconstructive Microsurgery

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1656719 ◽

2018 ◽

Vol 34 (09) ◽

pp. 669-671 ◽

Cited By ~ 1

Author(s):

David Chuang

Keyword(s):

Nerve Transfer ◽

Elbow Flexion ◽

Nerve Graft ◽

Reconstructive Procedure ◽

Nerve Reconstruction ◽

Nerve Grafts ◽

Advantages And Disadvantages ◽

Nerve Transfers ◽

Reconstructive Microsurgery ◽

Distal Nerve

Abstract Background Nerve transfer can be broadly separated into two categories: proximal nerve graft and/or transfer and distal nerve transfer. The superiority of proximal nerve graft/transfer over distal nerve transfer strategy has been debated extensively, but which strategy is the best has not yet been defined. Each technique has its own advantages and disadvantages. However, proximal nerve graft/transfer is still the main reconstructive procedure based on the principle of “no diagnosis, then no treatment.” Proximal nerve transfer can avoid iatrogenic injury where the lesion is still in continuity and neurolysis is the only procedure without further cutting the nerve. Results Our clinical and experimental study show that proximal nerve grafts/transfers yield at least equal or better results compared to distal nerve transfers. Proximal nerve grafts/transfers remain the mainstay of my reconstructive strategy. Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow functions simultaneously. Distal nerve transfers can offer more efficient elbow flexion. Conclusion Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available Distal nerve transfers should be considered as a complementary option for proximal nerve grafts/ transfers.

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Techniques of Peripheral Nerve Repair

Scandinavian Journal of Surgery ◽

10.1177/145749690809700407 ◽

2008 ◽

Vol 97 (4) ◽

pp. 310-316 ◽

Cited By ~ 64

Author(s):

L. B. Dahlin

Keyword(s):

Peripheral Nerve ◽

Nerve Repair ◽

Correct Diagnosis ◽

Nerve Injuries ◽

Nerve Roots ◽

Postoperative Rehabilitation ◽

Cold Intolerance ◽

Peripheral Nerve Repair ◽

Nerve Grafts ◽

Nerve Transfers

Nerve injuries extend from simple nerve compression lesions to complete nerve injuries and severe lacerations of the nerve trunks. A specific problem is brachial plexus injuries where nerve roots can be ruptured, or even avulsed from the spinal cord, by traction. An early and correct diagnosis of a nerve injury is important. A thorough knowledge of the anatomy of the peripheral nerve trunk as well as of basic neurobiological alterations in neurons and Schwann cells induced by the injury are crucial for the surgeon in making adequate decisions on how to repair and reconstruct nerves. The technique of peripheral nerve repair includes four important steps (preparation of nerve end, approximation, coaptation and maintenance). Nerves are usually repaired primarily with sutures applied in the different tissue components, but various tubes are available. Nerve grafts and nerve transfers are alternatives when the injury induces a nerve defect. Timing of nerve repair is essential. An early repair is preferable since it is advantageous for neurobiological reasons. Postoperative rehabilitation, utilising the patients' own coping strategies, with evaluation of outcome are additional important steps in treatment of peripheral nerve injuries. In the rehabilitation phase adequate handling of pain, allodynia and cold intolerance are emphasised.

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Same Modality nerve Reconstruction for Accessory nerve Injuries

Otolaryngology ◽

10.1016/j.otohns.2008.09.006 ◽

2008 ◽

Vol 139 (6) ◽

pp. 854-856 ◽

Cited By ~ 5

Author(s):

Christina K. Magill ◽

Amy M. Moore ◽

Susan E. Mackinnon

Keyword(s):

Sural Nerve ◽

Motor Nerve ◽

Nerve Transfer ◽

Functional Results ◽

Neck Surgery ◽

Obturator Nerve ◽

Accessory Nerve ◽

Nerve Injuries ◽

Nerve Reconstruction ◽

Nerve Grafts

The standard repair of a nerve gap under tension is to use a sensory autograft, such as the medial antebrachial cutaneous or the sural nerve. The practice of using sensory grafts to repair motor nerve defects is challenged by the discovery of preferential motor reinnervation and modality specific nerve regeneration. In this article, two clinical cases are presented where accessory nerve injuries are repaired with either a motor nerve transfer (a branch of C7) or a motor autograft (obturator nerve), and excellent functional results are reported. These cases provide a stimulus to consider the use of motor nerve grafts or transfers in the repair of motor nerve deficits. © 2008 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

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An Experimental Study of Contralateral C7 Root Transfer with Vascularized Nerve Grafting to Treat Brachial Plexus Root Avulsion

Journal of Hand Surgery (European Volume) ◽

10.1016/0266-7681(94)90051-5 ◽

1994 ◽

Vol 19 (1) ◽

pp. 60-66 ◽

Cited By ~ 27

Author(s):

L. CHEN ◽

Y-D. GU

Keyword(s):

Brachial Plexus ◽

Ulnar Nerve ◽

Phrenic Nerve ◽

Nerve Transfer ◽

Nerve Graft ◽

Functional Evaluation ◽

Nerve Grafting ◽

Root Avulsion ◽

Nerve Grafts ◽

Healthy Side

Experimental rat models of simulated brachial plexus injuries were devised to compare the effect of contralateral C7 root transfer with phrenic neurotization. The effect of vascularized nerve grafting (VNG) was also compared with the use of conventional nerve grafts (CNG) in the treatment of root avulsion of the brachial plexus. 160 rats were randomly divided into four groups of 40 each; contralateral C7 root transfer with a vascularized ulnar nerve graft (C7-VNG), contralateral C7 root transfer with conventional ulnar nerve grafting (C7-CNG), ipsilateral phrenic nerve transfer with a vascularized ulnar nerve graft (P-VNG) and ipsilateral phrenic nerve transfer with conventional ulnar nerve grafting (P-CNG). Electrophysiological and histological examinations and functional evaluation were performed at different post-operative intervals. C7 root transfer was found to be superior to phrenic nerve transfer and VNG superior to CNG. Severance of the C7 nerve root was not found to affect limb function on the healthy side.

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Surgical repair of brachial plexus injury: a multinational survey of experienced peripheral nerve surgeons

Neurosurgical FOCUS ◽

10.3171/foc.2004.16.5.13 ◽

2004 ◽

Vol 16 (5) ◽

pp. 1-11 ◽

Cited By ~ 2

Author(s):

Allan J. Belzberg ◽

Michael J. Dorsi ◽

Phillip B. Storm ◽

John L. Moriarity

Keyword(s):

Peripheral Nerve ◽

Brachial Plexus ◽

Surgical Intervention ◽

Nerve Repair ◽

Nerve Transfer ◽

Elbow Flexion ◽

Medical Community ◽

Shoulder Abduction ◽

Nerve Transfers ◽

The Many

Background Brachial plexus injuries (BPIs) are often devastating events that lead to upper-extremity paralysis, rendering it a painful extraneous appendage. Fortunately, there are several nerve repair techniques that provide restoration of some function. Although there is general agreement in the medical community concerning which patients may benefit from surgical intervention, the actual repair technique for a given lesion is less clear. Object The authors sought to identify and better define areas of agreement and disagreement among experienced peripheral nerve surgeons regarding the management of BPIs. Methods The authors developed a detailed survey in two parts: one part addressing general issues related to BPI and the other presenting four clinical cases. The survey was mailed to 126 experienced peripheral nerve physicians of whom 49 (39%) participated in the study. The respondents represented 22 countries and multiple surgical subspecialties. They performed a mean of 34 brachial plexus reconstructions annually. Areas of significant disagreement included the timing and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, the best transfers to achieve elbow flexion and shoulder abduction, the use of intra- or extraplexal donors for motor neurotization, and the use of distal compared with proximal coaptation during nerve transfer. Conclusions Experienced peripheral nerve surgeons disagreed in important respects as to the management of BPI. The decisions made by the various treating physicians underscored the many areas of disagreement regarding the treatment of BPI including the diagnostic approach to defining the injury, timing of and indications for surgical intervention in birth-related palsy, management of neuroma-in-continuity, choice of nerve transfers to achieve elbow flexion and shoulder abduction, use of intra- or extraplexal donors for neurotization, and the use of distal or proximal coaptation during nerve transfer.

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Motor Nerve Transfers

Neurosurgery ◽

10.1227/neu.0000000000001029 ◽

2015 ◽

Vol 78 (1) ◽

pp. 1-26 ◽

Cited By ~ 34

Author(s):

Wilson Z. Ray ◽

Jason Chang ◽

Ammar Hawasli ◽

Thomas J. Wilson ◽

Lynda Yang

Keyword(s):

Peripheral Nerve ◽

Brachial Plexus ◽

Marked Improvement ◽

Spinal Cord Injuries ◽

Motor Nerve ◽

Nerve Transfer ◽

Nerve Grafting ◽

Peripheral Nerve Injuries ◽

Nerve Injuries ◽

Nerve Transfers

Abstract Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.

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Nerve graft versus nerve transfer for neonatal brachial plexus: shoulder outcomes

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.6.peds2027 ◽

2021 ◽

Vol 27 (1) ◽

pp. 87-92

Author(s):

Brandon W. Smith ◽

Kate W. C. Chang ◽

Sravanthi Koduri ◽

Lynda J. S. Yang

Keyword(s):

Brachial Plexus ◽

Clinical Data ◽

External Rotation ◽

Nerve Transfer ◽

Shoulder Function ◽

Nerve Transfers ◽

Shoulder Flexion ◽

Significant Difference ◽

Transfer Strategies ◽

Shoulder External Rotation

OBJECTIVEThe decision-making in neonatal brachial plexus palsy (NBPP) treatment continues to have many areas in need of clarification. Graft repair was the gold standard until the introduction of nerve transfer strategies. Currently, there is conflicting evidence regarding outcomes in patients with nerve grafts versus nerve transfers in relation to shoulder function. The objective of this study was to further define the outcomes for reconstruction strategies in NBPP with a specific focus on the shoulder.METHODSA cohort of patients with NBPP and surgical repairs from a single center were reviewed. Demographic and standard clinical data, including imaging and electrodiagnostics, were gathered from a clinical database. Clinical data from physical therapy evaluations, including active and passive range of motion, were examined. Statistical analysis was performed on the available data.RESULTSForty-five patients met the inclusion criteria for this study, 19 with graft repair and 26 with nerve transfers. There were no significant differences in demographics between the two groups. Understandably, there were no patients in the nerve grafting group with preganglionic lesions, resulting in a difference in lesion type between the cohorts. There were no differences in preoperative shoulder function between the cohorts. Both groups reached statistically significant improvements in shoulder flexion and shoulder abduction. The nerve transfer group experienced a significant improvement in shoulder external rotation, from −78° to −28° (p = 0.0001), whereas a significant difference was not reached in the graft group. When compared between groups, there appeared to be a trend favoring nerve transfer in shoulder external rotation, with the graft patients improving by 17° and the transfer patients improving by 49° (p = 0.07).CONCLUSIONSIn NBPP, patients with shoulder weakness experience statistically significant improvements in shoulder flexion and abduction after graft repair or nerve transfer, and patients with nerve transfers additionally experience significant improvement in external rotation. With regard to shoulder external rotation, there appear to be some data supporting the use of nerve transfers.

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Radial Nerve Palsy: Nerve Transfer Versus Tendon Transfer to Restore Function

Hand ◽

10.1177/1558944720988126 ◽

2021 ◽

pp. 155894472098812

Author(s):

J. Megan M. Patterson ◽

Stephanie A. Russo ◽

Madi El-Haj ◽

Christine B. Novak ◽

Susan E. Mackinnon

Keyword(s):

Radial Nerve ◽

Tendon Transfer ◽

Nerve Palsy ◽

Nerve Transfer ◽

Pinch Strength ◽

Radial Nerve Palsy ◽

Nerve Injuries ◽

Tendon Transfers ◽

Nerve Transfers ◽

Transfer Group

Background: Radial nerve injuries cause profound disability, and a variety of reconstruction options exist. This study aimed to compare outcomes of tendon transfers versus nerve transfers for the management of isolated radial nerve injuries. Methods: A retrospective chart review of 30 patients with isolated radial nerve injuries treated with tendon transfers and 16 patients managed with nerve transfers was performed. Fifteen of the 16 patients treated with nerve transfer had concomitant pronator teres to extensor carpi radialis brevis tendon transfer for wrist extension. Preoperative and postoperative strength data, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and quality-of-life (QOL) scores were compared before and after surgery and compared between groups. Results: For the nerve transfer group, patients were significantly younger, time from injury to surgery was significantly shorter, and follow-up time was significantly longer. Both groups demonstrated significant improvements in grip and pinch strength after surgery. Postoperative grip strength was significantly higher in the nerve transfer group. Postoperative pinch strength did not differ between groups. Similarly, both groups showed an improvement in DASH and QOL scores after surgery with no significant differences between the 2 groups. Conclusions: The nerve transfer group demonstrated greater grip strength, but both groups had improved pain, function, and satisfaction postoperatively. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. Both tendon transfers and nerve transfers are good options for patients with radial nerve palsy.

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