Yan-Qun Qiu

Phrenic Nerve Transfer for Elbow Flexion and Intercostal Nerve Transfer for Elbow Extension

PURPOSEnTo explore long-term recovery of elbow flexion and extension after transferring the phrenic nerve and intercostal nerves, respectively, in adults with global brachial plexus avulsion injuries.nnnMETHODSnSeven adults with global brachial plexus avulsion injuries had the phrenic nerve transferred to the musculocutaneous nerve (or to the anterior division of upper trunk) and intercostal nerves transferred to the triceps branch of the radial nerve at our hospital 7 to 12 years ago. The results of elbow motor strength testing using the Medical Research Council grading scale, and electrodiagnostic findings using electromyogram examinations, were studied retrospectively. Pulmonary function tests were also performed at final visits.nnnRESULTSnFunctional elbow flexion was obtained in most of the 7 cases (M2, 1; M3, 3; M4, 2; and M5, 1) but elbow extension was absent or insufficient in all subjects (M0, 1; M1, 3; and M2, 3). Electrical results showed successful biceps reinnervation in 6 patients and successful triceps reinnervation in 5. No patient experienced breathing problems, and pulmonary function results were within normal range.nnnCONCLUSIONSnIn the long term, after brachial plexus avulsion injury in most patients who underwent both phrenic nerve and intercostal nerve transfer to achieve elbow flexion and extension eventually obtained satisfactory elbow flexion but poor elbow extension. We recommend against transferring the intercostal nerves to the triceps branch of radial nerve in conjunction with primary phrenic to musculocutaneous nerve transfer.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic IV.

Long-term ongoing cortical remodeling after contralateral C-7 nerve transfer

OBJECTnContralateral C-7 nerve transfer was developed for the treatment of patients with brachial plexus avulsion injury (BPAI). In the surgical procedure the affected recipient nerve is connected to the ipsilateral motor cortex, and the dramatic peripheral alteration may trigger extensive cortical reorganization. However, little is known about the long-term results after such specific nerve transfers. The purpose of this study was to investigate the long-term cortical adaptive plasticity after BPAI and contralateral C-7 nerve transfer.nnnMETHODSnIn this study, 9 healthy male volunteers and 5 male patients who suffered from right-sided BPAI and had undergone contralateral C-7-transfer more than 5 years earlier were included. Functional MRI studies were used for the investigation of long-term cerebral plasticity.nnnRESULTSnThe neuroimaging results suggested that the ongoing cortical remodeling process after contralateral C-7 nerve transfer could last for a long period; at least for 5 years. The motor control of the reinnervated limb may finally transfer from the ipsilateral to the contralateral hemisphere exclusively, instead of the bilateral neural network activation.nnnCONCLUSIONSnThe authors believe that the cortical remodeling may last for a long period after peripheral rearrangement and that the successful cortical transfer is the foundation of the independent motor recovery.

Hand prehension recovery after brachial plexus avulsion injury by performing a full-length phrenic nerve transfer via endoscopic thoracic surgery

OBJECTnThe functional recovery of hand prehension after complete brachial plexus avulsion injury (BPAI) remains an unsolved problem. The authors conducted a prospective study to elucidate a new method of resolving this injury.nnnMETHODSnThree patients with BPAI underwent a new procedure during which the full-length phrenic nerve was transferred to the medial root of the median nerve via endoscopic thoracic surgery support. All 3 patients were followed up for a postoperative period of > 3 years.nnnRESULTSnThe power of the palmaris longus, flexor pollicis longus, and the flexor digitorum muscles of all 4 fingers reached Grade 3-4/5, and no symptoms of respiratory insufficiency occurred.nnnCONCLUSIONSnNeurotization of the phrenic nerve to the medial root of the median nerve via endoscopic thoracic surgery is a feasible means of early hand prehension recovery after complete BPAI.

Contralateral Peripheral Neurotization for Hemiplegic Upper Extremity After Central Neurologic Injury

BACKGROUNDnCentral neurological injury (CNI) is a major contributor to physical disability that affects both adults and children all over the world. The main sequelae of chronic stage CNI are spasticity, paresis of specific muscles, and poor selective motor control. Here, we apply the concept of contralateral peripheral neurotization in spasticity releasing and motor function restoration of the affected upper extremity.nnnOBJECTIVEnA clinical investigation was performed to verify the clinical efficacy of contralateral C7 neurotization for rescuing the affected upper extremity after CNI.nnnMETHODSnIn the present study, 6 adult hemiplegia patients received the nerve transfer surgery of contralateral C7 to C7 of the affected side. Another 6 patients with matched pathological and demographic status were assigned to the control group that received rehabilitation only. During the 2-year follow-up, muscle strength of bilateral upper extremities was assessed. The Modified Ashworth Scale and Fugl-Meyer Assessment Scale were used for evaluating spasticity and functional use of the affected upper extremity, respectively.nnnRESULTSnBoth flexor spasticity release and motor functional improvements were observed in the affected upper extremity in all 6 patients who had surgery. The muscle strength of the extensor muscles and the motor control of the affected upper extremity improved significantly. There was no permanent loss of sensorimotor function of the unaffected upper extremity.nnnCONCLUSIONnThis contralateral C7 neurotization approach may open a door to promote functional recovery of upper extremity paralysis after CNI.

Long-term observation of respiratory function after unilateral phrenic nerve and multiple intercostal nerve transfer for avulsed brachial plexus injury.

BACKGROUND: Phrenic nerve transfer (PNT) or multiple intercostal nerve transfer (MIT) alone are reported to have no significant impact on pulmonary function in the short or medium term, but it has rarely been reported whether the combination of PNT-MIT could influence respiratory function in the long term. OBJECTIVE: Respiratory function was evaluated after PNT and PNT-MIT 7 to 19 years (mean, 10 years) postoperatively. METHODS: Twenty-three adult patients with brachial plexus avulsion injuries who underwent PNT-MIT were compared with 19 corresponding patients who underwent PNT. Pulmonary function testings, phrenic nerve conduction study, and chest fluoroscopy were performed. In the PNT-MIT group, further investigation was performed on the effect of the number of transferred intercostal nerves and the timing of MIT. RESULTS: In the PNT-MIT group, forced vital capacity, forced expiratory volume in one second, and total lung capacity were 73.69%, 72.04%, and 74.81% of predicted values without significant differences from the PNT group. Diaphragmatic paralysis permanently existed with 1 to 1.5 intercostal spaces (ICSs) elevation and near 1 ICS reduced excursion. There was no statistical difference between the PNT and PNT-MIT groups. Furthermore, 3 and 4 intercostal nerves transferred resulted in no further decrease in pulmonary function test results than 2 intercostal nerves. No significant difference was found when PNT and MIT were performed at the same stage or with an interval. CONCLUSION: PNT-MIT did not result in additional impairment in respiratory function in adult patients compared with PNT alone. It is safe to transfer 2 to 4 intercostal nerves at 1 to 2 months delay after PNT.

Arthroscopic Distal Metaphyseal Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome: A Different Technique

Ulnar impaction syndrome generally occurs with positive ulnar variance. The solution to the problem is to unload the ulnocarpal joint. Effective surgical options include diaphyseal ulnar shortening osteotomy, open wafer osteotomy, and arthroscopic wafer osteotomy. Recently, Slade and Gillon described an open procedure of ulnar shortening in the osteochondral region of the ulnar head. The procedure minimizes the risk of hemarthrosis and does not require hardware removal, which are problems with other surgical options. This article introduces a new arthroscopic technique of distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome. This technique offers the advantages of minimizing surgical injury to the dorsal capsule of the distal radoulnar joint and so protects its stability.

Local and Extensive Neuroplasticity in Carpal Tunnel Syndrome: A Resting-State fMRI Study:

Carpal tunnel syndrome (CTS) is a most common peripheral nerve entrapment neuropathy characterized by sensorimotor deficits in median nerve innervated digits. Block-design task-related functional magnetic resonance imaging (fMRI) studies have been used to investigate CTS-related neuroplasticity in the primary somatosensory cortices. However, considering the persistence of digital paresthesia syndrome caused by median nerve entrapment, spontaneous neuronal activity might provide a better understanding of CTS-related neuroplasticity, which remains unexplored. The present study aimed to investigate both local and extensive spontaneous neuronal activities with resting-state fMRI. A total of 28 bilateral CTS patients and 24 normal controls were recruited, and metrics, including amplitude of low-frequency fluctuation (ALFF) and voxel-wise functional connectivity (FC), were used to explore synaptic activity at different spatial scales. Correlations with clinical measures were further investigated by linear regression. Decreased amplitudes of low-frequency fluctuation were observed in the bilateral primary sensory cortex (SI) and secondary sensory cortex (SII) in CTS patients (AlphaSim corrected P < .05). This was found to be negatively related to the sensory thresholds of corresponding median nerve innervated fingers. In the voxel-wise FC analysis, with predefined seed regions of interest in the bilateral SI and primary motor cortex, we observed decreased interhemispheric and increased intrahemispheric FC. Additionally, both interhemispheric and intrahemispheric FC were found to be significantly correlated with the mean ALFF.

Contralateral Lumbar to Sacral Nerve Rerouting for Hemiplegic Patients After Stroke: A Clinical Pilot Study

BACKGROUNDnSpasticity and muscle weakness are common severe neurologic sequelae after stroke. Contralateral peripheral neurotization has been applied successfully to promote motor function of the hemiplegic upper extremity in patients with central neurological injury. To our knowledge, we present the first report of contralateral lumbar to sacral nerve transfer for the lower extremities in hemiplegic patients after stroke.nnnCASE DESCRIPTIONnTwo patients were enrolled in the study. The first patient is a 57-year-old man who experienced permanent muscle weakness in his left leg after a right cerebral infarction. The second patient is a 42-year-old man who had spasticity and hemiplegia in both upper and lower limbs on the right side 32 months after a left cerebral hemorrhage. Both patients underwent contralateral lumbar-to-sacral nerve rerouting to improve lower-limb motor function. Twenty months after surgery, both patients experienced significant improvement in ambulatory status.nnnCONCLUSIONSnAlthough long-term follow-up and a randomized controlled trial are required, this study demonstrates the safety and possible benefits of contralateral lumbar-to-sacral nerve transfer for hemiplegic patients after stroke. This novel surgical approach could provide a new means for lower-limb motor functional recovery.

Comparative effects of implanted electrodes with differing contact patterns on peripheral nerve regeneration and functional recovery

Electrical stimulation could enhance nerve regeneration and functional recovery. The objective of this study was to evaluate the regenerative effects of implanted electrodes with different contacts in resected sciatic nerve. Sciatic nerve resection and microsurgical repair models were established and randomly divided into four groups (point contact, 1/4 circle contact; whole-circle contact; no electrodes as control). Electrical stimulation was performed and electrophysiological, morphological and histological exams (of the sciatic nerve and muscle) were conducted at 4 and 10 weeks post-implantation. Point and 1/4 circle contact groups showed significantly higher scores in the sciatic functional index (SFI), increased amplitude of compound muscle action potential (AMP) and motor nerve conduction velocity (MNCV) compared to the control group at both 4 and 10 weeks post-implantation. Point and 1/4 circle contact morphologically promoted sciatic nerve regeneration and reduced muscular atrophy with less mechanical injury to the nerve trunk observed compared with the whole-circle contact group at both 4 and 10 weeks post-implantation. Electrodes with point and 1/4 circle contacts represented an alternatively portable and effective method of electrical stimulation to facilitate injured sciatic nerve regeneration and reduce subsequent muscular atrophy, which might offer a promising approach for treating peripheral nerve injuries.

Ultrasound in the management of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area: Ultrasound for nerve palsy

Introduction: The purpose of this study was to evaluate the application of ultrasound in the management of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area. Methods: In this retrospective study, we compared ultrasonographic results with intraoperative findings in patients with iatrogenic spinal accessory nerve palsy during the time period from 2014 to 2018 at our hospital. Results: Eleven patients were included. Ultrasound detected nerve transections in 9 patients and continuities in 2 patients. The ultrasonographic results were consistent with the intraoperative findings. Furthermore, ultrasound was able to accurately reveal lesion location in 8 of 9 patients with nerve transections. Discussion: Ultrasound provides direct images about nerve lesions contributing to the diagnosis of iatrogenic spinal accessory nerve palsy at the posterior cervical triangle area and also reveals lesion location, assisting in formulating suitable surgical plans preoperatively. We recommend that ultrasound be integrated into the preoperative evaluation. Muscle Nerve 59:64–69, 2019