Yu-Dong Gu

Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury.

&NA; Phrenic nerve transfer has been widely used in treating brachial plexus avulsion injury. However, the present method crosses the thoracic part of the phrenic nerve, and nerve graft is needed, resulting in a long period of regeneration and partly irreversible muscle atrophy. We present our early experience of using video‐assisted thoracic surgery to harvest a full length of phrenic nerve for transfer. Fifteen patients (mean age, 28 years) were treated. The thoracic part of the phrenic nerve was freed by means of video‐assisted thoracic surgery and taken out of the thoracic cavity, and a full‐length phrenic nerve was transferred to the musculocutaneous nerve to recover elbow flexion. The patients were followed. Another 29 patients with long‐term follow‐up who underwent traditional cervical phrenic nerve to musculocutaneous nerve transfer in our institute between 1994 and 1997 were selected. The period of newborn potential appearing in the biceps and the period for biceps to achieve M3 between two groups were compared. The operation was safe and no complications occurred. The additional length of phrenic nerve was 12.3 ± 4.5 cm. Eleven patients received sufficient follow‐up. Eight patients achieved biceps recovery to M3 (elbow flexion against gravity), and mean time was 198.8 ± 36.0 days, much earlier than that of the traditional method (p < 0.01). Pulmonary function recovered to the preoperative level 9 months after operation. This new method is safe and minimally invasive. The result of full‐length phrenic nerve transfer is much better than that of the traditional method. It obviously shortens the time required for nerve reinnervation, and offers a promising method for patients who have had a long interval from injury to operation and for forearm muscle reconstruction by phrenic nerve transferred to the median nerve or combined with free‐muscle transfer.

Adult rat mesenchymal stem cells differentiate into neuronal-like phenotype and express a variety of neuro-regulatory molecules in vitro.

Bone marrow stromal stem cells (MSCs), which normally differentiate into mesenchymal derivatives, have recently reported to trans-differentiate into neurons. However, the findings from different groups and interpretations have been challenged. The purpose of this paper is to re-evaluate the phenomenon of neuronal trans-differentiation of MSCs and compare the expression levels of neurotrophins in rMSCs and neuronal-like phenotypes derived from rMSCs. We put rMSCs in 2-mercaptoethanol and 2% dimethylsulfoxide for 5h. Then, the cells were transferred to neuronal induction media composed of DMEM+10%FBS, 10ug/L basic fibroblast growth factor, 10ug/L human epidermal growth factor, 1mmol dibutyryl cyclicn AMP and 0.5mmol isobutylmethylxanthine for 7 days and 14 days. The study demonstrated that the level of BDNF, NGF, NT3, CNTF and GDNF of rMSCs is remarkably higher in rMSCs than the neuronal-like phenotypes, especially CNTF. The expression level of these neurotrophins did not change significantly after enduring induction. We believed that rMSCs can trans-differentiate into neuronal-like phenotype under certain conditions. The non-induced rMSCs has a dynamic expression profile of neurotrophins and may serves as a better tool than the trans-differentiated rMSCs for transplant therapy.

Contralateral C7 transfer via the prespinal and retropharyngeal route to repair brachial plexus root avulsion: a preliminary report.

OBJECTIVEWe sought to investigate a shorter and safer route for contralateral C7 transfer. METHODSEight male patients were treated from December 2005 to November 2006. Their ages ranged from 22 to 43 years (average, 30 yr). Five patients had total brachial plexus avulsion. The operative delay was from 2 to 6 months (mean, 4 mo). The bilateral scalenus anterior muscles were transected before a prespinal and retropharyngeal tunnel was made. The contralateral C7 nerve root was used to repair the upper trunk or the infraclavicular lateral cord and posterior cord of the injured side via this route, with the use of direct neurorrhaphy or nerve grafting. RESULTSThe length of the harvested contralateral C7 nerve root was 4.67 ± 0.52 cm in the first five patients. The nerve graft was 6.25 ± 0.35 cm long for repairing supraclavicular brachial plexus and 8.56 ± 0.45 cm long for repairing infraclavicular brachial plexus. The length of the harvested contralateral C7 nerve root averaged 6.85 cm in the last three patients, two of whom had direct neurorrhaphy to the C5 and six residual nerve roots; in the other patient, a nerve graft 3 cm in length was used. Transient contralateral sensory symptoms were reported in most patients. In all cases, shoulder abduction and elbow flexion recovered by 12 months postoperatively. CONCLUSIONTransection of the bilateral scalenus muscles can reduce the length of the nerve graft and allow the C7 nerve to be transferred more smoothly and safely through the prespinal and retropharyngeal route; this method also favors nerve regeneration and functional recovery.

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

PURPOSE To 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. METHODS Seven 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. RESULTS Functional 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. CONCLUSIONS In 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. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Selective Neurotization of the Median Nerve in the Arm to Treat Brachial Plexus Palsy

BACKGROUND The current method for treatment of median nerve palsy after a brachial plexus injury is unpredictable. On the basis of an anatomic study of the median nerve in the arm, we present a new method of selective neurotization of the median nerve. METHODS Internal topographic features of the fascicular groups of the median nerve were observed in seventeen cadavera. On the basis of the anatomical results, selective neurotization of the posterior fascicular group of the median nerve in the arm was performed in one patient with a complete brachial plexus palsy. RESULTS In the distal half of the arm, the branches of the median nerve consistently collect into three fascicular groups, which are located at the anterior, middle, and posterior parts of the median nerve trunk. The anterior fascicular group is composed of the branches to the pronator teres and the flexor carpi radialis, the posterior fascicular group is composed mainly of the anterior interosseous nerve and the branches to the palmaris longus, and the middle fascicular group is made up mostly of the branches to the hand and the flexor digitorum superficialis. A transfer of the full length of the phrenic nerve was used to selectively reinnervate the posterior fascicular group of the median nerve in a patient with a complete brachial plexus palsy. The muscles supplied by the posterior fascicular group regained Grade-4 power, according to the system of the Medical Research Council, sixteen months after surgery. CONCLUSIONS The typical arrangement of the fascicular groups of the median nerve in the arm favors the technique of selective neurotization, which has been used effectively in one patient to date.

Selective neurotization of the median nerve in the arm to treat brachial plexus palsy. An anatomic study and case report.

BACKGROUND The current method for treatment of median nerve palsy after a brachial plexus injury is unpredictable. On the basis of an anatomic study of the median nerve in the arm, we present a new method of selective neurotization of the median nerve. METHODS Internal topographic features of the fascicular groups of the median nerve were observed in seventeen cadavera. On the basis of the anatomical results, selective neurotization of the posterior fascicular group of the median nerve in the arm was performed in one patient with a complete brachial plexus palsy. RESULTS In the distal half of the arm, the branches of the median nerve consistently collect into three fascicular groups, which are located at the anterior, middle, and posterior parts of the median nerve trunk. The anterior fascicular group is composed of the branches to the pronator teres and the flexor carpi radialis, the posterior fascicular group is composed mainly of the anterior interosseous nerve and the branches to the palmaris longus, and the middle fascicular group is made up mostly of the branches to the hand and the flexor digitorum superficialis. A transfer of the full length of the phrenic nerve was used to selectively reinnervate the posterior fascicular group of the median nerve in a patient with a complete brachial plexus palsy. The muscles supplied by the posterior fascicular group regained Grade-4 power, according to the system of the Medical Research Council, sixteen months after surgery. CONCLUSIONS AND CLINICAL RELEVANCE The typical arrangement of the fascicular groups of the median nerve in the arm favors the technique of selective neurotization, which has been used effectively in one patient to date.

Operative versus nonoperative treatment in the management of midshaft clavicular fractures: a meta-analysis of randomized controlled trials

BACKGROUND There is no consensus on the effects of operative versus nonoperative treatment on the outcomes of midshaft clavicular fractures in adults. We conducted a meta-analysis of randomized clinical studies. MATERIALS AND METHODS We searched the literature and included studies that investigated the effects of operative versus nonoperative intervention on the outcome of midshaft clavicular fractures. Patient data were pooled by use of standard meta-analytic approaches. For the continuous variables, the weighted mean difference was used. For dichotomous data, the relative risk was calculated. RESULTS Seven studies reported in 8 publications were eligible for data extraction. The pooled analyses showed that, compared with nonoperative treatment, operative treatment led to significantly lower incidences of nonunion and fewer symptomatic malunions. Subgroup analysis indicated that these advantages could be ascribed to plate fixation. Furthermore, surgery with plates resulted in significantly fewer complications. Patients undergoing surgery had better Disabilities of the Arm, Shoulder and Hand and Constant scores and lower dissatisfaction with their appearance. CONCLUSION In the management of midshaft clavicular fractures, surgery is superior to nonoperative treatment. Surgery with plates results in lower incidences of nonunion, fewer total complications, and fewer symptomatic malunions compared with nonoperative treatment.

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

OBJECT Contralateral 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. METHODS In 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. RESULTS The 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. CONCLUSIONS The 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.

Histopathologic study of the neuroma-in-continuity in obstetric brachial plexus palsy.

Background: Operative treatment of traction lesions in obstetric brachial plexus palsy is still controversial. The authors analyzed the histopathology of neuroma-in-continuity of the upper trunk by study of the resected neuroma. Methods: The neuroma-in-continuity of the upper trunk was studied histopathologically in 28 children with Erb palsy who had undergone resection of the neuroma and nerve reconstruction of the plexus at the age of 3 to 11 months. The authors recorded the distribution of myelinated motor nerve fibers and the proportions of collagen and regenerating nerve fibers traveling the neuroma, analyzed the relationship between the percentage of nerve fibers across the neuroma and findings of intraoperative neurophysiologic investigations and the patients age at surgery, and compared the number of nerve fibers in C5 and C6 proximal to the neuroma with that in their normal counterparts. Results: In the central segment of the neuroma, the structure of the upper trunk was replaced by copious collagen and sporadic nerve fibers wrapped by an undeveloped myelin sheath, and the percentage of collagen was statistically greater than that of the normal upper trunk. The mean percentage of regenerating nerve fibers across the neuroma was 41.83 percent (95 percent confidence interval, 38.69 to 44.69 percent) and this was not statistically correlated with the outcome of intraoperative neurophysiologic investigations or the patients age at surgery. The number of nerve fibers was statistically less in C5 and C6 proximal to the neuroma than in their normal counterparts. Conclusions: The nerve structure of the neuroma-in-continuity is substantially damaged in obstetric brachial plexus palsy. Its resection followed by nerve reconstruction of the plexus is favored.

Endoscopy-assisted cubital tunnel release under carbon dioxide insufflation and anterior transposition.

Purpose:The optimal treatment for cubital tunnel syndrome is widely debated. The purpose of this study is to describe the technique of an endoscopic-assisted ulnar nerve decompression using carbon dioxide insufflation in association with subcutaneous anterior transposition and to assess the success or failure of the method of treatment. Methods:In all, 8 male and 4 female patients with an average age of 42 years (range, 25–56) who presented signs, symptoms, and abnormal neurophysiological studies of cubital tunnel syndrome were recruited in the retrospective study. Between August 2008 and June 2009, they were operated on using a 0-degree lens endoscope. Preoperatively, they were classified according to the Dellon scale, and the Bishop rating system was used to evaluate the postoperative outcomes. Results:Preoperatively, 5 patients were rated as mild, another 5 as moderate, and the remaining 2 as severe. The average length of the incision was 15 ± 3 mm, the mean length of the ulnar nerve decompression was 18 ± 2 cm, and the whole duration of surgery (skin to skin) lasted 30 ± 5 minutes. The endoscopic-assisted cubital tunnel release under carbon dioxide insufflation and subcutaneous anterior transposition surgeries in all patients were performed with no difficulty. All the patients had improvement in symptoms of cubital tunnel syndrome and 10 of 12 patients scored excellent according to the modified Bishop Rating System at a minimum of 1 year after surgery. Conclusions:Endoscopy-assisted cubital tunnel release under carbon dioxide insufflation demonstrated similar results compared with conventional open surgeries, besides, it may avoid problems such as long incision, painful scarring, and have additional advantages of providing an extended endoscopic view, which is safe and mini-invasive with favorable results in a 12-month follow-up.