scholarly journals Distal nerve transfers: a biology-based rationale

2009 ◽  
Vol 26 (2) ◽  
pp. E12 ◽  
Author(s):  
Justin M. Brown ◽  
Manish N. Shah ◽  
Susan E. Mackinnon
Keyword(s):  
Cortical Plasticity ◽  
Surgical Repair ◽  
Donor Site ◽  
Nerve Transfer ◽  
Peripheral Nerve Injuries ◽  
Nerve Grafts ◽  
Nerve Transfers ◽  
Common Strategy ◽  
Distal Nerve ◽  
And Function

Peripheral nerve injuries can result in devastating numbness and paralysis. Surgical repair strategies have historically focused on restoring the original anatomy with interposition grafts. Distal nerve transfers are becoming a more common strategy in the repair of nerve deficits as these interventions can restore function in months as opposed to more than a year with nerve grafts. The changes that take place over time in the cell body, distal nerve, and target organ after axotomy can compromise the results of traditional graft placement and may at times be better addressed with the use of distal nerve transfers. A carefully devised nerve transfer offers restoration of function with minimal (if any) detectable deficits at the donor site. A new understanding of cortical plasticity along with patient reeducation allow for good return of strength and function after nerve transfer.

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

2018 ◽  
Vol 34 (09) ◽  
pp. 669-671 ◽  
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.

Anterior Interosseous–to–Ulnar Motor Nerve Transfers: A Single Center’s Experience in Restoring Intrinsic Hand Function

Hand ◽  
2020 ◽  
pp. 155894472092848
Author(s):  
Graham J. McLeod ◽  
Blair R. Peters ◽  
Tanis Quaife ◽  
Tod A. Clark ◽  
Jennifer L. Giuffre
Keyword(s):  
Outcome Measures ◽  
Motor Nerve ◽  
Hand Function ◽  
Donor Site ◽  
Nerve Transfer ◽  
Secondary Outcome ◽  
No Donor ◽  
Motor Branch ◽  
Nerve Transfers

Background: Transfer of the anterior interosseous nerve (AIN) into the ulnar motor branch improves intrinsic hand function in patients with high ulnar nerve injuries. We report our outcomes of this nerve transfer and hypothesize that any improvement in intrinsic hand function is beneficial to patients. Methods: A retrospective review of all AIN-to-ulnar motor nerve transfers, including both supercharged end-to-side (SETS) and end-to-end (ETE) transfers, from 2011 to 2018 performed by 2 surgeons was conducted. All adult patients who underwent this nerve transfer for any reason with greater than 6 months’ follow-up and completed charts were included. Primary outcome measures were motor function using the British Medical Research Council (BMRC) grading system and subjective satisfaction with surgery using a visual analog scale. Secondary outcome measures included complications and donor site deficits. Results: Of the 57 patients who underwent nerve transfer, 32 patients met the inclusion criteria. The average follow-up and average time to surgery were 12 and 15.6 months, respectively. The overall average BMRC score was 2.9/5, with a trend toward better recovery in patients who received earlier surgery (<12 months = BMRC 3.7, ≥12 months = BMRC 2.2; P < .01). Patients with an SETS transfer had better results that those with an ETE transfer (SETS = 3.2, ETE = 2.6). There were no donor deficits after operation. One patient developed complex regional pain syndrome. Conclusions: Patients with earlier surgery and an in-continuity nerve (receiving an SETS transfer) showed improved recovery with a higher BMRC grade compared with those who underwent later surgery. Any improvements in intrinsic hand function would be beneficial to patients.

scholarly journals Median to Radial Nerve Transfer to Restore Wrist and Finger Extension: Technical Nuances

2010 ◽  
Vol 66 (suppl_1) ◽  
pp. ons-75-ons-83 ◽  
Author(s):  
Justin M. Brown ◽  
Thomas H.H. Tung ◽  
Susan E. Mackinnon
Keyword(s):  
Radial Nerve ◽  
Nerve Palsy ◽  
Nerve Transfer ◽  
Radial Nerve Palsy ◽  
Tendon Transfers ◽  
Line Drawings ◽  
Nerve Transfers ◽  
Finger Extension ◽  
Reconstructive Option ◽  
Distal Nerve

Abstract Background: Traditional methods for restoring finger and wrist extension following radial nerve palsy include interposition nerve grafting or tendon transfers. We have described the utilization of distal nerve transfers for the restoration of radial nerve function in the forearm. Objective: We review the neuroanatomy of the forearm and outline the steps required for the implementation of this transfer. Methods And Results: We use a step-by-step procedural outline and detailed photographs, line drawings, and video to describe the procedure. Conclusion: This approach is technically feasible and is a reconstructive option for patients with this nerve deficit.

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

2018 ◽  
Vol 37 (04) ◽  
pp. 285-290
Author(s):  
Mario Siqueira ◽  
Roberto Martins ◽  
Wilson Faglioni Junior ◽  
Luciano Foroni ◽  
Carlos Heise
Keyword(s):  
Brachial Plexus ◽  
Median Nerve ◽  
Ulnar Nerve ◽  
Traumatic Injury ◽  
Surgical Techniques ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Nerve Transfers ◽  
Significant Difference ◽  
Distal Nerve

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 the median 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 + 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.

Contralateral lower trapezius transfer for restoration of shoulder external rotation in traumatic brachial plexus palsy: a preliminary report and literature review

2013 ◽  
Vol 39 (8) ◽  
pp. 861-867 ◽  
Author(s):  
N. G. Satbhai ◽  
K. Doi ◽  
Y. Hattori ◽  
S. Sakamoto
Keyword(s):  
Brachial Plexus ◽  
Glenohumeral Joint ◽  
External Rotation ◽  
Donor Site ◽  
Nerve Transfer ◽  
Shoulder Function ◽  
No Donor ◽  
Nerve Transfers ◽  
Shoulder External Rotation ◽  
Lower Trapezius

The importance of external rotation of the shoulder is well accepted. Patients with inadequate recovery of shoulder function after nerve transfers for a brachial plexus injury have difficulty in using their reconstructed limb. The options for secondary procedures to improve shoulder function are often limited, especially if the spinal accessory nerve has been used earlier for nerve transfer or as a donor nerve for a free functioning muscle transfer. We have used the contralateral lower trapezius transfer to the infraspinatus in three cases, to restore shoulder external rotation. All patients had significant improvement in shoulder external rotation (mean 97°; range 80°–110°) and improved disability of the arm, shoulder and hand scores. The rotation occurred mainly at the glenohumeral joint, and was independent of the donor side. All patients were greatly satisfied with the outcome. Contralateral lower trapezius transfer appears to help in overall improvement of shoulder function by stabilizing the scapula. The results have remained stable after mean follow-up of 58 months (range 12–86). No donor site deficit was seen in any patient.

scholarly journals Long-Term In Vivo Evaluation of Chitosan Nerve Guide Properties with respect to Two Different Sterilization Methods

2018 ◽  
Vol 2018 ◽  
pp. 1-11 ◽  
Author(s):  
Maria Stößel ◽  
Jennifer Metzen ◽  
Vivien M. Wildhagen ◽  
Olaf Helmecke ◽  
Lena Rehra ◽  
...  
Keyword(s):  
Peripheral Nerve Injuries ◽  
In Vivo Evaluation ◽  
Medical Products ◽  
Nerve Grafts ◽  
Nerve Guides ◽  
Surrounding Connective Tissue ◽  
Term Evaluation ◽  
Distal Nerve

Severe peripheral nerve injuries are reconstructed either with autologous nerve grafts (gold standard) or alternatively with clinically approved artificial nerve guides. The most common method used to sterilize these medical products is ethylene oxide gassing (EO). However, this method has several disadvantages. An alternative, which has been barely studied so far, represents beta irradiation (β). In previous studies, we developed an artificial nerve guide made of chitosan (chitosan nerve guide, CNG), a biomaterial that is known to potentially retain toxic residues upon EO sterilization. Therefore, we analyzed the long-term regeneration-supporting and mechanical properties of CNGs upon their sterilization with EO or β and their following application in unilateral repair of 12 mm gaps of the rat sciatic nerve. Over a period of 76 weeks, we serially evaluated the recovery of motor functions, the possible emergence of an inflammation in the surrounding connective tissue, the regrowth of axons into the distal nerve, and possible changes in the material properties. Our first long-term evaluation did not reveal significant differences between both sterilization methods. Thus, β is as appropriate as commonly used EO for sterilization of CNGs; however, it may slightly increase the stiffness of the biomaterial over time.

Future Perspectives in the Management of Nerve Injuries

2018 ◽  
Vol 34 (09) ◽  
pp. 672-674 ◽  
Author(s):  
Susan Mackinnon
Keyword(s):  
Brachial Plexus ◽  
Nerve Repair ◽  
Nerve Transfer ◽  
Functional Results ◽  
White Paper ◽  
Nerve Graft ◽  
Nerve Injuries ◽  
Nerve Grafts ◽  
Nerve Transfers ◽  
Reconstructive Microsurgery

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.

Elbow Flexion Reconstruction in Brachial Plexus Avulsion Injuries – Results with Intercostal Nerve and Distal Nerve Transfers

2020 ◽  
Vol 25 (03) ◽  
pp. 307-314
Author(s):  
Gavrielle Hui-Ying Kang ◽  
Rebecca Qian-Ru Lim ◽  
Fok-Chuan Yong
Keyword(s):  
Brachial Plexus ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Time Interval ◽  
Success Rates ◽  
Motor Branch ◽  
Entire Cohort ◽  
Brachial Plexus Avulsion ◽  
Nerve Transfers ◽  
Distal Nerve

Background: The neural surgical options for reconstruction of elbow flexion in brachial plexus injuries depend on the availability of nerve donors. In upper-type avulsion injuries, the ulnar or median nerves, when intact, are reliable intra-plexal donor nerves for transfers to the biceps muscle. In complete avulsion injuries, donors are limited to extra-plexal sources, such as intercostal nerves (ICNs). Methods: We reviewed our results of ICN and partial distal nerve (ulnar or median) transfers for elbow flexion reconstruction in patients with brachial plexus avulsion injuries. The time taken for recovery of elbow flexion strength to M3 and the final motor outcome at 2 years were compared between both groups. Results: 38 patients were included in this study. 27 had ICN transfers to the musculocutaneous nerve (MCN), 8 had partial ulnar nerve transfers and 3 had partial median nerve transfers to the MCN's biceps motor branch. The mean time interval from injury to surgery was 3.6 months. Recovery of elbow flexion was observed earlier in the distal nerve transfer group (p < 0.05). Overall, success rates were higher in patients with distal nerve transfers (100%), compared to ICN transfers (63%) at 2 years (p = 0.018). Patients with distal nerve transfers achieved a higher final median strength of M4.0 [Interquartile range (IQR) 3.5–4.5], compared to M3.5 (IQR 2.0–4.0) in the ICN group (p = 0.031). In the subgroup of patients with upper-type brachial plexus injuries, there were no significant differences in motor outcomes between the ICN versus distal nerve transfers group. Conclusions: In our entire cohort, patients with distal nerve transfers had faster motor recovery and better elbow flexion power than patients with ICN transfers. In patients with partial brachial plexus injuries, outcomes of ICN transfers were not inferior to distal nerve transfers.

Results of Distal Nerve Transfers in Restoration of Shoulder Function in C5 and C6 Root Avulsion Injury to the Brachial Plexus

2017 ◽  
Vol 14 (01) ◽  
pp. 021-025
Author(s):  
Prem Bhandari
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Nerve Transfer ◽  
Shoulder Function ◽  
Shoulder Abduction ◽  
Root Avulsion ◽  
Long Thoracic Nerve ◽  
Avulsion Injury ◽  
Nerve Transfers ◽  
Distal Nerve

Background The lack of shoulder function following brachial plexus injury is a debilitating condition. Nerve root avulsion injury precludes a direct nerve repair. Under these circumstances, distal nerve transfer is a well-established technique in the restoration of shoulder abduction and external rotation. Methods Thirty patients with C5 and C6 root avulsion injury were treated with distal nerve transfers in the period between February 2009 and December 2012.The average denervation period was 5.6 months. Shoulder function was restored by posterior transfer of distal part of the spinal accessory nerve into the suprascapular nerve and transfer of the long head triceps branch of radial nerve to the anterior branch of axillary nerve. An additional nerve transfer was performed in four patients with winged scapula by transferring a part of thoracodorsal nerve into the long thoracic nerve. Results Twenty-seven patients recovered shoulder abduction; 18 scored M4 and 9 scored M3. Range of abduction averaged 118 degrees (range, 90–170 degrees). Nineteen patients restored external rotation with an average of 53 degrees (range: 30–70 degrees). Three patients failed to recover shoulder abduction though the joint regained stability. External rotation remained severely restricted in 11 patients. At final follow-up, winging of scapula improved in three of four patients following reinnervation of the serratus anterior muscle. Conclusion Nerve transfers, when performed close to the target muscles, restore good range and strength of shoulder abduction in most patients with C5 and C6 root avulsion injuries. However, return in external rotation is not as good as the recovery in abduction.

scholarly journals Nerve transfers for severe brachial plexus injuries: a review

2004 ◽  
Vol 16 (5) ◽  
pp. 1-10 ◽  
Author(s):  
Rajiv Midha
Keyword(s):  
Brachial Plexus ◽  
Cortical Plasticity ◽  
Physiological Role ◽  
Nerve Transfer ◽  
Spinal Nerve ◽  
Major Goal ◽  
Nerve Transfers ◽  
Comprehensive Survey ◽  
Transfer Procedures

Nerve transfer procedures are increasingly performed for repair of severe brachial plexus injury (BPI), in which the proximal spinal nerve roots have been avulsed from the spinal cord. The procedure essentially involves the coaption of a proximal foreign nerve to the distal denervated nerve to reinnervate the latter by the donated axons. Cortical plasticity appears to play an important physiological role in the functional recovery of the reinnervated muscles. The author describes the general principles governing the successful use of nerve transfers. One major goal of this literature review is to provide a comprehensive survey on the numerous intra- and extraplexal nerves that have been used in transfer procedures to repair the brachial plexus. Thus, an emphasis on clinical outcomes is provided throughout. The second major goal is to discuss the role of candidate nerves for transfers in the surgical management of the common severe brachial plexus problems encountered clinically. It is hoped that this review will provide the treating surgeon with an updated list, indications, and expected outcomes involving nerve transfer operations for severe BPIs.

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