Nerve Reconstruction In Patients Research Articles

Spider silk erectile nerve reconstruction in robot-assisted radical prostatectomy: a first-in-men feasibility analysis.

To investigate the safety and feasibility of spider silk interposition for erectile nerve reconstruction in patients undergoing robotic radical prostatectomy (RARP). The major-ampullate-dragline from Nephila edulis was used for spider silk nerve reconstruction (SSNR). After removal of the prostate with either uni- or bilateral nerve-sparing, the spider silk was laid out on the site of the neurovascular bundles. Data analysis included inflammatory markers and patient reported outcomes. Six patients underwent RARP with SSNR. In 50% of the cases, only a unilateral nerve-sparing was performed, bilateral nerve-sparing could be performed in three patients. Placement of the spider silk conduit was uneventful, contact of the spider silk with the surrounding tissue was mostly sufficient for a stable connection with the proximal and distal ends of the dissected bundles. Inflammatory markers peaked until postoperative day 1 but stabilized until discharge without any need for antibiotic treatment throughout the hospital stay. One patient was readmitted due to a urinary tract infection. Three patients reported about erections sufficient for penetration after three months with a continuous improvement of erectile function both after bi- and unilateral nerve-sparing with SSNR up to the last follow-up after 18months. In this analysis of the first RARP with SSNR, a simple intraoperative handling without major complications was demonstrated. While the series provides evidence that SSNR is safe and feasible, a prospective randomized trial with long-term follow-up is needed to identify further improvement in postoperative erectile function due to the spider silk-directed nerve regeneration.

Intercostal Nerve Reconstruction for Severe Compensatory Hyperhidrosis: The Gebitekin Technique

Compensatory sweating (CS) is the most common and disabling complication of endoscopic thoracic sympathectomy and represents an unmet clinical challenge. Our surgical hypothesis is to generate a parallel pathway to the damaged part of the sympathetic nerve, similar to the Kuntz nerve, by reconstructing the 2 healthy intercostal nerves, thus treating CS. Here, we present a novel videothoracoscopic technique involving bilateral intercostal nerve reconstruction in patients with severe CS after endoscopic thoracic sympathectomy.

Outcomes of Late Microsurgical Nerve Reconstruction for Brachial Plexus Birth Injury

Microsurgical nerve reconstruction has been advocated between 3 and 9 months of life in select patients with brachial plexus birth injury (BPBI), yet some patients undergo indicated surgery after this time frame. Outcomes in these older patients remain poorly characterized. We analyzed outcomes of nerve reconstruction performed after 9 months of age and hypothesized that (1) Active Movement Scale (AMS) scores improve after surgery, and (2) there are no differences in AMS scores between patients undergoing nerve transfers versus those undergoing nerve grafting. From 2000 to 2014, 750 patients at 6 U.S. centers were prospectively enrolled in a multicenter database. We included patients treated with nerve reconstruction after 9 months of age with minimum 12 months' follow-up. Patients were evaluated using AMS scores. To focus on the results of microsurgery, only outcomes prior to secondary surgery were analyzed. We analyzed baseline variables using bivariate statistics and change in AMS scores over time and across treatment groups using linear mixed models. We identified 32 patients (63% female) with median follow-up of 29.8 months. Median age at microsurgery was 11.2 months. Twenty-five (78%) had an upper trunk injury. Compared with before surgery, total AMS scores improved modestly at 1 year and 2 or more years follow-up. At 1 year follow-up, AMS scores improved for shoulder function (abduction, external rotation) and elbow flexion. Between-group comparisons found no differences in total AMS scores or AMS subscales between graft and transfer groups at 1 year or 2 or more years after surgery, so we cannot recommend one strategy over the other based on our findings. Overall, nerve reconstruction in patients with BPBI after 9 months of age resulted in improved function over time. There was no difference in outcomes between nerve transfer and nerve graft groups and 1 or 2 or more years follow-up. Therapeutic IV.

Outcomes of shoulder abduction after nerve surgery in patients over 50 years following traumatic brachial plexus injury

There is controversy regarding the effectiveness of brachial plexus reconstruction in older patients, as outcomes are thought to be poor. The aim of this study is to determine the outcomes of shoulder abduction obtained after nerve reconstruction in patients over the age of 50 years and factors related to success. Forty patients over the age of 50 years underwent nerve surgery to improve shoulder function after a traumatic brachial plexus injury. Patients were evaluated pre- and postoperatively for shoulder abduction strength and range of motion (ROM); Disability of the Arm, Shoulder and Hand (DASH) scores; pain; age bracket; gender; body mass index (BMI); delay from injury to operation; concomitant trauma; severity of trauma; and type of reconstruction. The average age was 58.2 years (range 50-77 years) with an average follow-up of 18.8 months. The average modified British Medical Research Council (BMRC) shoulder abduction grade improved significantly from 0.23 to 2.03 (p < 0.005). Fourteen patients achieved functional shoulder abduction of ≥ M3 postoperatively. There was no correlation between age or age range stratification and BMRC grade or those obtaining useful shoulder abduction ≥ M3. Active shoulder abduction improved significantly from 18.25° to 40.64°, with no difference on the basis of age or age stratification. There were improved modified BMRC grades with nerve transfers versus nerve grafts. Less patients achieved ≥ M3 function if surgery was delayed > 6 months. The mean DASH score decreased from 45.3 to 40.7 postoperatively, and the average pain score decreased from 3.7 to 3.0. Patients with a higher postoperative BMRC grade for shoulder abduction had improved postoperative DASH scores and VAS for pain (p = 0.011 and 0.005, respectively). Brachial plexus nerve reconstruction for shoulder abduction in patients over the age of 50 years can yield useful BMRC scores and ROM, and age should not be used to exclude nerve reconstruction in these patients.

Contralateral medial pectoral nerve transfer with free gracilis muscle transfer in old brachial plexus palsy

BackgroundThere is a very small chance of success for nerve reconstruction in patients with old total brachial plexus palsy who visit after 2 y or suffer from flail upper extremity after the failure of previous operations. Materials and methodsFor these individuals, the surgeon has to find a recipient motor nerve to perform free gracilis muscle transplantation. In this study, contralateral medial pectoral nerve from the intact side was transferred to the damaged side as a recipient nerve. Then, in the second operation, approximately 15 mo later, the free gracilis muscle transfer was performed. The gracilis muscle was removed and transferred to provide elbow and finger flexion. ResultsIn a retrospective study (over 10 y), we reviewed 68 patients for whom this method had been performed. After 1 y, the results were investigated using the Medical Research Council grading system. Five patients did not participate in the study, and the muscle underwent necrosis in two patients. M3 and M4 muscle power was regained in 26 (42.6%) and 21 (34.4%) patients, respectively. ConclusionsContralateral pectoral nerve transfer followed by free muscle transplantation can be a good option for patients with old total brachial plexus palsy.

How late is too late for nerve transfers

Traditionally, the degeneration of the motor endplates has placed a limit on the accepted delay for nerve reconstruction. Nerve transfers have helped to deliver growing axons very close to the target muscles so that the post-operative denervation is shortened. Despite efforts at spreading awareness of surgical indications, there are instances where the patient presents late to a specialized brachial plexus unit. In such cases, one faces the dilemma of using traditional nerve transfers or opting for a free functioning muscle transfer. Some surgeons rely on the presence of fibrillations on the EMG to help them decide about the feasibility of re-innervation. However, there are no clear guidelines. I would like to present a study of 50 patients operated at 9 months or later (9-19.5 months) from the accident. I have excluded cases operated later than April 2013, as the follow-up is too short. Their ages ranged from 4-57 years with a mean of 28.6 years (31 of the 50 patients belonged the range 10-30 years). There were 15 total palsies, 15 cases of C567 palsies, 9 cases of C56 palsies, one case of isolated C8T1 involvement and 10 infraclavicular palsies (injuries beyond the trunks). Among the nerve transfers for elbow flexion, intercostals were transferred to the musculocutaneous in 15 cases. Biceps of at least grade 3 strength was restored in 5/15 patients. Ulnar to biceps transfer was done in 22 cases (+median to brachialis in 16 of these). 17 of these patients regained elbow flexion stronger than grade 3. The spinal accessory nerve was transferred to the suprascapular nerve in 34 cases and grade 3 supraspinatus was achieved in 20 patients. However, the cases of successful restoration of shoulder abduction included 7 patients with C56 palsies and 4 of C567 palsies. Thus, from these observations it appears that: 1. In total palsies, the failure rate of intercostals to musculocutaneous and spinal accessory to suprascular nerve transfers is far higher than the overall average in my series. 2. The failure rate for ulnar to biceps transfer remains unchanged even up to 19.5 months from the accident. 3. Shoulder abduction is a reasonable expectation after a nerve transfer in a partial palsy even at delays longer than 10 months. I recommend that one should not succumb to the temptation to perform traditional nerve reconstruction in patients with flail upper limbs that present late, even if they are young. The available nerve transfers should be utilized for innervation of free functioning muscles. On the other hand, we can continue to have an optimistic outlook for C56 palsies even at delays as long as 18-19 months.

Nerve regeneration across cryopreserved allografts from cadaveric donors: a novel approach for peripheral nerve reconstruction

The use of allografts from cadaveric donors has attracted renewed interest in recent years, and pretreatment with cryopreservation and immunosuppression methods has been investigated to maximize axonal regrowth and minimize allograft rejection. The authors wanted to assess the outcome of treatments of brachial plexus stretch injuries with cryopreserved allografts from cadaveric donors in nonimmunosuppressed patients. Ten patients with brachial plexus lesions were submitted to electromyography (EMG) testing 1 and 3 months after a traumatic event and 1 week before surgery to localize and identify the type of lesion. Intraoperative EMG recordings were performed for intraoperative monitoring to select the best surgical strategy, and postoperative EMG was used to follow up patients and determine surgical outcomes. If nerve action potentials (NAPs) were present intraoperatively, neurolysis was performed, whereas muscular/nerve neurotization was performed if NAPs were absent. Cryopreserved allografts obtained from selected cadaveric donors and provided by the tissue bank of Treviso were used for nerve reconstruction in patients who were not treated with immunosuppressive drugs. The surgical strategy was selected according to the type and site of the nerve lesion and on the basis of IOM results: 14 cryopreserved allografts were used for 7 muscular neurotizations and for 7 nerve neurotizations, and 5 neurolysis procedures were performed. All of the patients had regained motor function at the 1- and 2-year follow-ups. Some variables may affect functional recovery after allograft surgery, and the outcome of peripheral nerve reconstruction is more favorable when patients are carefully evaluated and selected for the surgery. The authors demonstrated that using cryopreserved allografts from cadaveric donors is a valid surgical strategy to restore function of the damaged nerve without the need for any immunosuppressive treatments. This approach offers new perspectives on procedures for extensive reconstruction of brachial and lumbosacral plexuses.

End-to-side neurorrhaphy in brachial plexus reconstruction

Although a number of theoretical and experimental studies dealing with end-to-side neurorrhaphy (ETSN) have been published to date, there is still a considerable lack of clinical trials investigating this technique. Here, the authors describe their experience with ETSN in axillary and musculocutaneous nerve reconstruction in patients with brachial plexus palsy. From 1999 to 2007, out of 791 reconstructed nerves in 441 patients treated for brachial plexus injury, the authors performed 21 axillary and 2 musculocutaneous nerve sutures onto the median, ulnar, or radial nerves. This technique was only performed in patients whose donor nerves, such as the thoracodorsal and medial pectoral nerves, which the authors generally use for repair of axillary and musculocutaneous nerves, respectively, were not available. In all patients, a perineurial suture was carried out after the creation of a perineurial window. The overall success rate of the ETSN was 43.5%. Reinnervation of the deltoid muscle with axillary nerve suture was successful in 47.6% of the patients, but reinnervation of the biceps muscle was unsuccessful in the 2 patients undergoing musculocutaneous nerve repair. The authors conclude that ETSN should be performed in axillary nerve reconstruction but only when commonly used donor nerves are not available.

The End-to-Side Neurorrhaphy in Axillary Nerve Reconstruction in Patients with Brachial Plexus Palsy

Sir:FigureAlthough a number of theoretical and experimental studies dealing with end-to-side neurorrhaphy have been published to date, there is still a considerable lack of clinical trials. In this communication, we describe our experience with end-to-side neurorrhaphy in axillary nerve reconstruction in patients with upper brachial plexus palsy. Of 791 reconstructed nerves in 441 patients operated on from 1993 to 2011, we performed 21 axillary nerve sutures onto median, ulnar, and radial nerves from 1999 to 2007. This technique was performed only in patients whose “classic donors” such as the thoracodorsal or long thoracic nerve that we generally use for repair of the axillary nerve were not available. The average age of the patients was 32 years. The average time between the trauma and surgery was 4.8 months (Table 1).Table 1: Data for Patients with End-to-Side Neurorrhaphy of the Axillary Nerve onto the DonorIn all patients, a perineurial suture was carried out after the creation of a perineurial window (Fig. 1). It is our standard technique because it has been shown in experimental models that the success rate of such sutures is much higher.1 The precise site on the donor nerve where end-to-side neurorrhaphy was to be performed was chosen by direct bipolar electrical stimulation and registration in the corresponding muscle. There were no signs of denervation of the donor nerve after the perineurial window was created in experimental models.1,2 Similarly, none of our patients had any sensory or motor loss in the innervation zone of the donor nerve, contrary to the Oberlin technique, which carries a risk of sensory loss and, rarely, weakness of hand movements.5Fig. 1: End-to-side neurorrhaphy of the axillary nerve (A) onto the ulnar nerve (UN).The axillary nerve reinnervated successfully in 10 of 21 patients (average follow-up, 30.7 months; Medical Research Council grade 3 to 4 during shoulder abduction over 30 degrees). In four patients, no electrophysiologic signs of reinnervation were observed. In contrast, seven patients whose electromyograms showed reinnervation potentials exhibited insufficient deltoid function (Medical Research Council grade 1, and in one case, grade 2). The success rate was 47.6 percent. The use of different donor nerves (ulnar or median) did not affect the success rate. In the study with the largest series of patients published to date, the author reported good results with reconstructions of various nerves in the upper extremities. These results, however, are not comparable to our study because of a large variety of both donors and recipients.4 We previously reported successful reinnervation using end-to-side neurorrhaphy in 64 percent of patients. These results were based on 14 patients who completed a sufficient follow-up period.3 In the present study, the success rate was 47.6 percent, suggesting that the chance of successful reinnervation using end-to-side neurorrhaphy is lower than we previously thought. The results of end-to-side neurorrhaphy in brachial plexus reconstruction are similar to neurotization using the extraplexus nerves as donors of motor nerve fibers in end-to-end neurotization. Generally, a limited amount of motoneurons have the capacity to send off collateral sprouts from intact axons.2 We conclude that end-to-side neurorrhaphy should be used in adult brachial plexus reconstructive surgery only if “classic donor nerves” are not available. One advantage of end-to-side neurorrhaphy over “classic” neurotization is that there is no need to sacrifice the surrounding nerves or fascicles of the ulnar nerve (Oberlin technique). Pavel Haninec, M.D., Ph.D. Radek Kaiser, M.D. Third Faculty of Medicine, Charles University, Department of Neurosurgery, Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this article. ACKNOWLEDGMENT This study was supported by grants IGA NS 10496-3/2009 and MSM 0021620816.

Vein Wrapping Technique for Nerve Reconstruction in Patients with Thyroid Cancer Invading the Recurrent Laryngeal Nerve

Recurrent laryngeal nerve paralysis is the most common and serious complication after thyroid cancer surgery. The objective of this study was to report the advantages of the vein wrapping technique for nerve reconstruction in patients with thyroid cancer invading the recurrent laryngeal nerve and its effects on postoperative phonatory function. The subjects were three patients who underwent resection of the recurrent laryngeal nerve during surgical extirpation of papillary thyroid cancer. Free ansa cervicalis nerve graft or direct neurorrhaphy with a vein wrapping technique was used to facilitate nerve regeneration, protect the anastomosed nerve site mechanically, and prevent neuroma formation. One-year postoperative laryngoscopic examination revealed good vocal cord mobility. Maximum phonation time (19.5 ± 0.3 sec) was longer than a previously-reported value in conventional reconstruction patients (18.8 ± 6.6 sec). The present phonation efficiency index (7.88 ± 0.78) was higher than that previously calculated in conventional reconstruction (7.59 ± 2.82). The mean value of the Voice Handicap Index-10 was 6, which was within the normal range. This study demonstrates improvement in phonation indices measured 1 year after recurrent laryngeal nerve reconstruction. Our results confirm that the vein wrapping technique has theoretical advantages and could be favored over conventional reconstruction techniques for invenerate nerve injuries.

Our experience with triceps nerve reconstruction in patients with brachial plexus injury

Although elbow extension is facilitated by gravity, triceps muscle provides elbow joint stability; in patients with brachial plexus injuries stable elbow is necessary for obtaining useful hand function. This study presents the senior author's experience with triceps nerve reconstruction and the functional results in patients with brachial plexus injuries. Outcomes were analyzed in relation to denervation time, severity score, length of the interposition nerve graft and donor nerves used. One hundred and sixty two patients with brachial plexus injury had triceps nerve neurotization and elbow extension recovery between 1978 and 2006. The mean patient's age was 25.45 ± 9.90 years and the mean denervation time was 16.90 ± 26.95 months. Two hundred and thirty two motor donors were used in 156 patients; 6 patients underwent neurolysis; 86 intercostal nerves were transferred in 41 patients. Interposition nerve grafts were used in 130 patients. Results were good or excellent in 31.65% of patients. The age of patients and the severity of the brachial plexus lesion are among the factors that significantly influenced functional results. Intraplexus motor donors are always preferable achieving better functional outcomes than extraplexus donors. Intercostal nerves and the posterior division of contralateral C7 proved preferred donors for elbow extension restoration in multiple avulsions. Although it is difficult to restore strong elbow extension, triceps nerve reconstruction is suggested in brachial plexus management, since it provides elbow stability. Satisfactory elbow extension strength was restored in young patients with high severity score.

Nerve reconstruction in patients with obstetric brachial plexus injury results in worsening of glenohumeral deformity: A case-control study of 75 patients

Nerve reconstruction in patients with obstetric brachial plexus injury results in worsening of glenohumeral deformity: A case-control study of 75 patients

Nerve reconstruction in patients with obstetric brachial plexus injury results in worsening of glenohumeral deformity

Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction. This study suggests that less invasive management, addressing the muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover.

Local administration of DFO-loaded lipid particles improves recovery after end-to-end reconstruction of rat median nerve

The improvement of regeneration and functional recovery after peripheral nerve injury is a major challenge in neurosurgery. Although microsurgical techniques for nerve reconstruction have seen great advancements over the last years, the clinical outcome with patients is often unsatisfactory. The aim of the present study was to investigate if administration of the iron chelator Deferroxamine (DFO), can improve postoperative outcome in the rat median nerve reconstruction model. After complete transection, the right median nerve was repaired by end-to-end neurorrhaphy. The suture site was wrapped by a 1-cm-long external jugular vein segment, either empty or filled with DFO-loaded lipid particles (Perineurin or with a vehicle (unloaded lipid particles) alone. Functional testing was carried out weekly by means of the grasping test. At the time of withdrawal, 12 weeks post-operatively, muscle tropism recovery was assessed by weighing flexor digitorum sublimis muscle that is innervated by the median nerve only. Before harvesting of the nerve specimens electrophysiological analyses were performed with measuring the latency, the threshold and the conduction velocity. Finally, the repaired nerves were withdrawn for immunocytochemistry with a neurofilament antibody and axon quantitative morphology. The comparison between the groups showed that intraoperative application of the DFO-loaded lipid particles at the neurorrhaphy site led to a significant increase in the density of regenerating axons as well as to an accelerated recovery of both muscle tropism and motor function. The electrophysiological results demonstrated a decrease of the threshold, a lower latency, and a higher conduction velocity in the Perineurin-treated animals. The results of the present study suggest that local administration of Perineurin might have a therapeutic potential for improving the postoperative outcome after microsurgical nerve reconstruction in patients.

Reconstruction of Recurrent Laryngeal Nerve With Involvement by Metastatic Node in Esophageal Cancer

Recurrent laryngeal nerve paralysis represents one of the major complications in esophageal cancer surgery, and patients with esophageal cancer sometimes develop recurrent laryngeal nerve paralysis before treatment. We evaluated recurrent laryngeal nerve reconstruction in patients with lymph node metastasis infiltrating the recurrent laryngeal nerve. Five patients with preoperative recurrent laryngeal nerve paralysis as a result of involvement of metastasis were enrolled in the present study. Ansa cervicalis-recurrent laryngeal nerve anastomosis in the neck was performed in 4 patients and direct anastomosis of recurrent laryngeal nerve in the mediastinum in 1 patient. Six months after surgery, 3 patients who had undergone ansa cervicalis-recurrent laryngeal nerve anastomosis in the neck displayed good quality of life without hoarseness or aspiration. The patient who underwent direct anastomosis of the recurrent laryngeal nerve in the mediastinum experienced occasional aspiration and hoarseness. The remaining patient displayed poor condition because of recurrent lung tumor, and quality of life was decreased. If patients with recurrent laryngeal nerve paralysis before treatment can undergo potentially curative resection with lymph node dissection, including the metastatic lymph node infiltrating the recurrent laryngeal nerve, recurrent laryngeal nerve reconstruction should be performed to improve quality of life.

Vascularized nerve grafts for the treatment of large nerve gap after severe trauma to an upper extremity.

We reviewed the clinical outcomes of vascularized nerve grafts for the repair of large nerve gaps (longer than 20 cm) after severe trauma to an upper extremity. Six patients who underwent vascularized sural nerve grafting (five to the median nerve and one to the ulnar nerve) with a monitoring skin flap were evaluated. The length of the vascularized sural nerve grafts ranged from 20 to 30 cm, with a mean length of 23.3 cm. All but one of the monitoring skin flap grafts was successful. In those patients for whom the monitoring skin flap graft was successful, the mean static-2PD at the corresponding fingertip was 14.2 mm (range 10-20 mm). Evaluation of these patients with the Semmes-Weinstein test produced the following results: filament 6, two patients; filament 10, three patients. The results of this study show that vascularized sural nerve grafting should be considered as a clinical alternative for nerve reconstruction in patients with nerve defects longer than 20 cm.