Haodong Lin

Clinical study of reconstructed bladder innervation below the level of spinal cord injury to produce urination by Achilles tendon-to-bladder reflex contractions.

OBJECT Neurogenic bladder dysfunction following spinal cord injury (SCI) is a major medical and social problem for which there is no ideal treatment strategy. In the present study, the authors analyze the effectiveness of neurogenic bladder reinnervation in patients with SCIs by using Achilles tendon reflexes below the paraplegic level. METHODS Spinal root anastomoses were performed in 12 paraplegic patients with hyperreflexic neurogenic bladder and detrusor external sphincter dyssynergia (DESD) caused by complete suprasacral SCI, in an attempt to reinnervate the bladder. The surgery anastomosed the unilateral proximal end of the S-1 ventral root and the distal end of the S-2 and/or S-3 ventral roots to build the Achilles tendon-to-bladder reflex, while the S-1 dorsal root was kept intact as the trigger for micturition after axonal regeneration. All patients underwent urodynamic evaluation before surgery and at follow-up. RESULTS The mean follow-up duration was 3 years. Of the 12 patients, 9 (75%) regained satisfactory bladder control within 6 to 12 months after ventral root microanastomosis. In these 9 patients, urodynamic studies revealed a change from detrusor hyperreflexia with DESD and high detrusor pressure to almost normal storage and synergic voiding without DESD. The average bladder capacity increased from 258 +/- 33 ml to 350 +/- 49 ml, residual urine decreased from 214 +/- 36 ml to 45 +/- 11 ml, and urinary infections were not observed. Patients with impaired renal function experienced a full recovery. Three patients failed to show any improvement after the operation. CONCLUSIONS These results suggest the effectiveness of bladder innervation below the level of SCI to produce urination by Achilles tendon-to-bladder reflex contractions, and might therefore provide a new clinical approach to reconstructing spasmodic bladder urination function.

Transfer of the phrenic nerve to the posterior division of the lower trunk to recover thumb and finger extension in brachial plexus palsy.

OBJECT Hand function is severely impaired in cases of lower root avulsion. In the present study, the authors investigated the clinical effectiveness and safety of phrenic nerve transfer to the posterior division of the lower trunk of the brachial plexus to recover thumb and finger extension. METHODS Between 2004 and 2006, 10 patients with brachial plexus palsy underwent phrenic nerve transfer as part of a strategy for surgical reconstruction of their plexuses. The mean patient age of was 27.2 years (range 18-44 years), and the mean interval from injury to surgery was 5.7 months (range 3-9 months). The phrenic nerve was always transferred to the posterior division of the lower trunk. RESULTS The follow-up of the patients ranged from 2.5 to 4.4 years, with an average follow-up length of 3.5 years. There were no major complications related to the surgery. Eight patients recovered to Grade 3 or better (Medical Research Council grade) in extensor digitorum strength, and 7 patients recovered to Grade 3 or better in extensor pollicis strength. None of the patients had any clinical signs or symptoms of respiratory insufficiency. CONCLUSIONS Satisfactory thumb and finger extension can be achieved by phrenic nerve transfer to the posterior division of the lower trunk of the brachial plexus. This procedure is simple and less traumatic than that of transferring the phrenic nerve to the radial nerve. It is indicated in cases in which the brachial plexus is relatively intact at the division level.

Innervation of reconstructed bladder above the level of spinal cord injury for inducing micturition by contractions of the abdomen-to-bladder reflex arc.

Medical management is often the initial management of cervical spondylitic syndromes, including radiculopathy, myelopathy, and neck pain. This includes pharmacological and rehabilitation treatment. Prospective studies comparing the efficacy of surgical versus medical management are lacking. The indications and efficacy of pharmacological and rehabilitative treatments are reviewed. The use of anti-inflammatory drugs, muscle relaxants, analgesics, antidepressants, anticonvulsants, steroids, facet joint ablation, and physical therapy are reviewed. A rationale for the medical management of acute neck pain, chronic neck pain, radiculopathy, and myelopathy is presented.

Long-term Outcome of Using Posterior-thigh Fasciocutaneous Flaps for the Treatment of Ischial Pressure Sores

Among the many difficult problems presented by patients with spinal cord injuries, management of ischial pressure ulcers remains challenging for reconstructive surgeons. This study describes the long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores. Between January 1999 and June 2003, 12 patients with ischial sores were enrolled in this study. All the patients underwent early aggressive surgical debridement followed by surgical reconstruction with a laterally based posterior-thigh fasciocutaneous flap. The follow-up period ranged from 24 months to 97 months (mean, 62 months). All the flaps survived, and there were no partial flap losses. Primary-wound healing occurred in all the cases. In two patients, Grade II ischial pressure sores recurred 24 months and 27 months after the operation. There was no recurrence in the other 10 patients. The posterior-thigh fasciocutaneous pedicled flap was a good method for treating ischial bed sores. This flap could be used to treat recurrences observed after primary bed-sore treatment with other methods. The flap was easy to raise, and it did not cause any donor-site morbidity. The long-term outcome of using posterior-thigh fasciocutaneous flaps for the treatment of ischial pressure sores was generally good.

Transfer of the superior portion of the pectoralis major flap for restoration of shoulder abduction.

Shoulder function is frequently impaired or lost following brachial plexus injuries. We introduce a novel method of restoring shoulder abduction by transferring the superior portion of the major flap of the pectoralis. Between March 1998 and June 2003, eight patients with insufficient abduction of the shoulder joint were treated with transfer of the superior portion of the pectoralis major flap. The mean follow-up period was 6 years. In all cases, shoulder mobility was improved. The mean increase in active abduction was from 6 degrees to 74 degrees. The mean forward flexion increased from 10 degrees to 75 degrees, and subluxation was abolished. All patients were satisfied with their improvement in function. Transfer of the superior portion of the pectoralis major flap is an easy and practicable method to restore abduction without serious complications. The patients achieved good stability and functionality of the shoulder.

Contralateral L-6 nerve root transfer to repair lumbosacral plexus root avulsion: experimental study in rhesus monkeys.

OBJECT Nerve transfer is used for brachial plexus injuries but has rarely been applied to repairs in the lower extremities. The aim of this study was to evaluate the feasibility and effectiveness of using the contralateral L-6 nerve root to repair lumbosacral plexus root avulsions. METHODS Eighteen rhesus monkeys were randomized into 3 groups. In the experimental group, the left L4-7 and S-1 nerve roots were avulsed and the right L-6 nerve root was transferred to the left inferior gluteal nerve and the sciatic nerve branch innervating the hamstrings. In the control group, the left L4-7 and S-1 nerve roots were avulsed and nerve transfer was not performed. In the sham operation group, the animals underwent a procedure that did not involve nerve avulsion and nerve transfer. Functional outcomes were measured by electrophysiological study, muscle mass investigation, and histological study. RESULTS The mean amplitudes of the compound muscle action potentials from the gluteus maximus and biceps femoris in the experimental group were higher than those in the control group but lower than those in the sham group (p < 0.05). The muscle mass and myofiber cross-sectional area of these muscles were heavier and larger than those in the control group (p < 0.05). The number of myelinated nerve fibers of the inferior gluteal nerve and the branch of the sciatic nerve innervating the hamstrings in the control group was significantly smaller than the number in the experimental and sham groups (p < 0.01). CONCLUSIONS In this animal model, the contralateral L-6 (analogous to S-1 in humans) nerve root can be used to repair lumbosacral plexus root avulsion.

Treatment of Ischial Pressure Sores Using a Modified Gracilis Myofasciocutaneous Flap

Despite the availability of a variety of flap reconstruction options, ischial pressure sores continue to be the most difficult pressure sores to treat. This article describes a successful surgical procedure for the coverage of ischial ulcers using a modified gracilis myofasciocutaneous flap. From August 2000 to April 2004, 12 patients with ischial sores were enrolled in the study. All patients underwent early aggressive surgical debridement followed by surgical reconstruction with a modified gracilis myofasciocutaneous flap. The follow-up period ranged from 13 to 86 months, with a mean of 44 months. Overall, 91.7% of the flaps (11 of 12) survived primarily. Partial flap necrosis occurred in one patient. Primary wound healing occurred without complications at both the donor and recipient sites in all cases. In one patient, grade II ischial pressure sores recurred 13 months after the operation. There was no recurrence in other 11 patients. A modified gracilis myofasciocutaneous flap provides a good cover for ischial pressure sores. Because it is easy to use and has favorable results, it can be used in the primary treatment for large and deep ischial pressure sores.

Reinnervation of Atonic Bladder after Conus Medullaris Injury Using a Modified Nerve Crossover Technique in Canines

BACKGROUND Neurogenic bladder represents a major cause of morbidity in patients with spinal cord injuries (SCI). Herein, we evaluated a novel reconstructive surgical technique designed to restore afferent and efferent nerve function in atonic bladder caused by conus medullaris injury. MATERIALS AND METHODS A new reflex pathway was established by extradural transfer of the left L5 ventral root (VR) to the left S2 VR root together with extradural postganglionic spinal nerve transfer of the L5 dorsal root (DR) to the S2 DR with a nerve graft in a canine model. The corresponding nerves on the right side were kept intact and served as a control. After the new reflex pathway was reestablished, the early function of the reflex arc was evaluated by electrophysiologic study, intravesical pressure, and histologic examination. RESULTS Action potential (AP) curves were recorded with single focal stimulation of the left S2 DR before and after the spinal cord was destroyed horizontally between the L6 and S3 levels. Bladder contraction was successfully initiated by trains of stimuli targeting the left L5-S2 DR anastomosis. Achievable bladder pressures and the amplitude of bladder smooth muscle complex action potentials were unchanged before and after induced paraplegia and were comparable to those of the control. Prominent axonal sprouting was observed in the distal region of the nerve graft. CONCLUSION Both afferent and efferent nerve pathways in the atonic bladder were reconstructed by suprasacral motor-to-motor and sensory-to-sensory extradural nerve transfer in canines. Taken together, these findings suggest a new potential clinical approach for restoring bladder function in individuals with paraplegia.

Long-term outcome of division of the C8 nerve root for spasticity of the hand in cerebral palsy.

Division of the C8 nerve root results in short-term relief of spasticity in the hands of cerebral palsy patients. In the present study, we assessed the long-term outcome of C8 nerve root division. Between March 1997 and January 2002, this procedure was done in 13 patients. All received consistent postoperative functional rehabilitation training. The hands were assessed before operation and at follow-up using the Lazareff grading system. The average follow-up time was 8.6 years. Two hands showed excellent improvement, three limbs showed good improvement and eight hands showed no improvement. No long-term complications occurred in any patient. These results indicate that the long-term outcome of C8 nerve root rhizotomy for the treatment of hand spasticity in CP is generally poor.

Repair of a lateral malleolus defect with a composite pedicled second metatarsal flap

The patient was a 26-year-old man who fell while riding a motorcycle and friction led to defects in the lateral malleolus and soft tissue of the ankle. Although the wound surface healed with scarring and skin grafting, the patient had symptoms of ankle joint instability 4 months after the injury. Using a second metatarsal composite tissue flap with a dorsalis pedis artery pedicle, we repaired the soft tissue defect of the ankle and reconstructed the lateral malleolus. The head of the metatarsal bone was used to reconstruct the lateral malleolus and the flap was used to cover the wound surface. The distal fibula and metatarsus were completely healed 36 months postoperatively. The ankle had maintained stability at this time, with equal limb length and only a mild limitation of dorsal flexion in the ankle joint. The patient could walk, jog, and walk up and down stairs without limitations. There was no pain or limitation in activity at the donor site. Our findings suggest that the second metatarsal composite tissue flap with a dorsalis pedis artery pedicle is an effective option in reconstruction of the adult distal fibula.