Terminolateral Neurorrhaphy Research Articles

Functional Outcomes 18 Months After Total and Midarm Transplantation: A Case Report

BackgroundThe function reported after arm transplantation is deemed beneficial relative to the marked disability that upper arm amputation causes. ObjectiveWe report a 51-year-old man with a Disabilities of the Arm, Shoulder and Hand (DASH) score of 75.83 who underwent bilateral arm transplantation in October 2015. ProcedureThe right arm was transplanted at the glenohumeral joint level, including transplantation of the humeral head, joint capsule, and rotator cuff ligaments and tendons. Additionally, neurorrhaphies were performed at the origin of the terminal branches of the brachial plexus, including the axillary and musculocutaneous nerves. Therefore, this was considered a total arm transplantation. The left arm was transplanted at the transhumeral level, with complete transplantation of the biceps and triceps brachii, and terminolateral neurorrhaphy of the donor musculocutaneous nerve to the receptor radial nerve. A maintenance triple immunosuppression scheme was administered, with tacrolimus levels kept at 10 ng/mL. ResultsAt 18 months post-transplantation, the intrinsic musculature in the left hand showed electrical registry, DASH score was 67.5, Carroll test score was 28 in both extremities, Hand Transplant Score System was 67.5 in the right extremity and 77.5 in the left extremity, and Short Form-36 score was 96.1. The patient was healthy, with restored body integrity. He could lift medium-sized weightless objects, eat and go to the bathroom by himself, drink liquids with bimanual grasp, swim, dress almost independently, and drive. ConclusionThe functional evolution of the patient was similar to previously reported transplanted arms, even though the right arm transplant involved the glenohumeral joint and axillary and musculocutaneous nerve repair.

Anatomical and Microsurgical Implications in Total and Midarm Transplantation

Background Arm transplantations are performed less frequently than forearm and hand transplantations. We present the surgical and microsurgical technique and its relationship with the clinical results in a patient with bilateral arm transplantation. Methods A 51-year-old male patient underwent bilateral arm transplantation in October 2015. The right arm was transplanted at the glenohumeral joint. The vascular repair was at the axillary level, and the nerves were repaired at their origin. The total ischemia time was 3 hours and 48 minutes. The left arm was transplanted at the midhumeral level; all muscles were completely transplanted. The nerves were repaired at the distal third of the arm. Additionally, terminolateral neurorrhaphy was performed from the donor musculocutaneous nerve to the recipient radial nerve. The total ischemia time was 6 hours and 35 minutes. Results At 15 months posttransplantation, the right shoulder had an abduction of 90 degrees and muscle strength of M4; flexion of 100 degrees and M4; internal and external rotation of M1; elbow flexion of 120 degrees and M3; elbow extension of M5; pronosupination of M2; and wrist extension of M2. There was no mobility in the fingers. The left transplanted limb had total elbow flexion and extension of M5, pronosupination of M2, wrist extension of M4, and finger flexion of M2. Both extremities had thermal sensitivity that allowed discrimination of cold and heat with residual deep pressure. Conclusion Although the functional results of arm transplantation are so far unknown, they may be considered beneficial compared with the devastating disability caused by arm amputation.

Treating facial nerve palsy by true termino-lateral hypoglossal–facial nerve anastomosis

Hypoglossal-facial nerve anastomosis is a time-proven technique for the repair of facial nerve palsy. Efforts have been made to reduce hypoglossal nerve injury, the main drawback of the technique. In this study, the anastomosis is a true termino-lateral neurorrhaphy with only an epineural window in the hypoglossal nerve sheath. A re-routing technique of the temporal facial nerve is also performed to allow a direct anastomosis to the hypoglossal nerve without the need for a jump graft. The first three results reported are very encouraging, with a satisfactory return of facial mimics and without any impairment of lingual function.

The promotion of nerve regeneration in peripheral nerve by progesterone after terminolateral neurorrhaphy: an experiment study

目的 探讨黄体酮对外周神经端侧吻合后神经侧芽生长及远段神经再生的影响.方法选用雌性SD大鼠36只,周龄9～10周.随机分为2组,黄体酮(PROG)组和对照组,每组18只.两组均先切除双侧卵巢,2周后行腓总神经和胫神经端侧吻合术.PROG组:切断左侧腓总神经,在同侧的胫神经干外膜上开一面积为1 mm×1 mm小窗,将腓总神经远端吻合到胫神经干侧方开窗处,近端反转包埋于附近肌肉内.经臀部肌内每日注射PROG注射液(10 mg/ml)0.2 ml;对照组:吻合方法同PROG组,术后注射等量的茶油0.2ml.各组分别于术后4周、8周、12周进行神经电生理、组织学和形态定量学检测.结果外周神经端侧吻合后,两组腓总神经均有一定程度再生.PROG组在各时间点,运动神经传导速度、腓总神经远端再生有髓神经纤维截面积、再生有髓神经纤维数目均明显优于对照组(P＜0.05).透射电镜结果显示PROG组较对照组髓鞘更为成熟,轴索再生明显.结论黄体酮可以促进外周神经端侧吻合后神经侧芽生长及远段神经再生和功能恢复.

Impact of epineurial excision of the distal recipient nerve in terminolateral neurorrhaphy.

Different surgical modifications were studied to improve success in terminolateral neurorrhaphy. The authors evaluated the efficacy of distal epineurial excision of the recipient nerve stump. Forty male Wistar rats were evaluated in four groups. The right hind limbs of the animals were used as experimental limbs and the left hind limbs as control limbs. The peroneal nerve was transected at a level 1 cm above the bifurcation of the tibial nerve. The proximal stump of the peroneal nerve was covered with gluteus maximus muscle fibers in all groups. In Group 1, the distal peroneal nerve was not processed and was left in the operative field. In Group 2, the distal peroneal nerve stump was sutured to an epineurial window on the tibial nerve by epineurial neurorrhaphy. In Group 3, the distal stump of the peroneal nerve was buried in the tibial nerve without epineurial resection, and in Group 4 with a 1-mm epineurial excision. Walking track analyses, electromyographic studies, and histomorphometric analyses were performed after a 3-month follow-up period. Statistical analysis was done with ANOVA and Tukey tests. No important donor-nerve injury was detected. Axonal regeneration and functional results were better in Group 4 compared to Groups 2 and 3. An increased donor and recipient nerve contact surface area with the excision of the epineurium from the distal peroneal nerve stump (Group 4) might provide superior results with longer follow-up periods.

Study of Axonal Regeneration in Terminolateral Neurorrhaphy of the Tibioperoneal Nerve in Rats

Purpose: The purpose of this study was to compare the degree of axonal regeneration between end-toend and terminolateral neurorrhaphy, and determine the degree of nerve regeneration for each method of terminolateral neurorrhaphy. Materials and Methods: Thirty-two Sprague-Dawley rats (N=64) were divided into four experimental groups: End-to-end neurorrhaphy (Group 1), end-to-side neurorrhaphy without removal of the epineurial sheath (Group 2), with an epineurial window (Group 3), and with an epineurial window combined with tibial motor axonotomy (Group 4). Each group were sacrificed after needle electromyography at 2, 4, 8, and 12 weeks and transmission electron microscopy was performed to observe the histologic findings of coaptation sites. The weights of tibialis anterior muscles were measured. Results: The amplitude of the compound motor action potential was always lowest in group 4, and there was no statistically significant difference between groups 2 and 3 in terms of the ratio of myelinated to non-myelinated nerve fiber. However, there was a statistically significant difference between groups 2 and 3 in terms of the thickness of the myelin sheath. The tibialis anterior muscle weight in Group 1 increased more so than in the other groups and there was statistically significant difference between group 1 and 4. Conclusion: End-to-end neurorrhaphy is the best method of nerve repair, and there was no statistically significant difference between epineurial and epineurial window coaptation in end-to-side neurorrhapy.

Terminolateral neurorrhaphy: a review of the literature.

Terminolateral neurorrhaphy (TLN) is an experimental technique for repairing peripheral nerves, when the proximal cut nerve stump is not available for traditional end-to-end repair. Over the past 7 years, the efficacy of TLN, its ability to preserve donor nerve function, the necessity of disrupting donor nerve connective tissue layers during the procedure, the mechanism by which TLN affords reinnervation, and the definition of the procedure, have been debated. In this critical review of TLN literature, the authors attempt to demonstrate 1) that a TLN in which the surgeon deliberately transects donor nerve axons is an effective method for peripheral nerve repair; the mechanisms by which axons innervate target muscles following this procedure are well-defined, and there is adequate experimental and clinical evidence to support its clinical application; and 2) that a TLN procedure in which the surgeon attempts to leave the donor nerve intact is neither mechanistically distinct from a TLN with deliberate donor nerve axotomy, nor is it as efficacious. Future studies should assess the degree of donor nerve transection that will maximize reinnervation via the TLN graft, without incurring functionally significant donor nerve deficits.

Terminolateral neurorrhaphy: review of experimental and clinical studies.

Since the reintroduction of the terminolateral neurorrhaphy (TLN) concept by Viterbo in 1992, several published articles and abstracts have been reported in the English literature. This report was prepared to investigate the following subjects: source of current research on TLN, animal models, methods of assessment of axonal regeneration, the source of regenerating axons, sensory vs. motor collateral sprouting, effects on the donor nerve, cellular events following TLN, factors affecting axonal regeneration and, finally, end-to-side nerve repair in the human patient.

Termino‐lateral neurorrhaphy: The functional axonal anatomy

The goal of this study was to determine the functional axonal anatomy of a termino-lateral neurorrhaphy (TLN). We hypothesize that axons populating a TLN must relinquish functional connections with their original targets prior to establishing new connections via the TLN. Two-month-old F344 rats underwent a TLN between the left peroneal nerve and a nerve graft tunneled to the contralateral hindlimb. Three months postoperatively, an end-to-end neurorrhaphy was performed between the nerve graft and the right peroneal nerve. Four months after the second operation, contractile properties and electromyographic (EMG) signals were measured in the bilateral hindlimbs. Left peroneal nerve stimulation proximal to the TLN site resulted in bilateral extensor digitorum longus (EDL) and tibialis anterior (TA) muscle contractions, with significantly lower forces on the side reinnervated by TLN. Evoked EMGs demonstrated that the right and left hindlimb musculature were electrically discontinuous following TLN. These data support our hypothesis that axons can form functional connections via a TLN, but they must first relinquish functional connections with their original targets. © 2000 Wiley-Liss, Inc. MICROSURGERY 20:6–14 2000

Termino-lateral neurorrhaphy: the functional axonal anatomy.

The goal of this study was to determine the functional axonal anatomy of a termino-lateral neurorrhaphy (TLN). We hypothesize that axons populating a TLN must relinquish functional connections with their original targets prior to establishing new connections via the TLN. Two-month-old F344 rats underwent a TLN between the left peroneal nerve and a nerve graft tunneled to the contralateral hindlimb. Three months postoperatively, an end-to-end neurorrhaphy was performed between the nerve graft and the right peroneal nerve. Four months after the second operation, contractile properties and electromyographic (EMG) signals were measured in the bilateral hindlimbs. Left peroneal nerve stimulation proximal to the TLN site resulted in bilateral extensor digitorum longus (EDL) and tibialis anterior (TA) muscle contractions, with significantly lower forces on the side reinnervated by TLN. Evoked EMGs demonstrated that the right and left hindlimb musculature were electrically discontinuous following TLN. These data support our hypothesis that axons can form functional connections via a TLN, but they must first relinquish functional connections with their original targets.

END-TO-SIDE NERVE SUTURE IN THE HUMAN PATIENT

End-to-side nerve suture (also called terminolateral neurorrhaphy) has been extensively examined clinically, histologically, electro-physiologically and electron microscopically in the rat and non-human primat (Chacma baboon: Papua ursinus). We have demonstrated good to excellent sensory in motor function results in the human patient for a variety of nerve injuries. The simplicity of the procedure, the relative wide tolerance of the operative technique and the virtual consistent early recovery of both sensory and motor function, makes this method ideal for nerve injury surgery. Nerve grafts to a large extent are obviated and brachial plexus surgery gets a whole new meaning. The first 22 patients are presented.

Results of termino-lateral neurorrhaphy to original and adjacent nerves.

In this comprehensive investigation, we studied three different neurorrhaphy models in an attempt to elucidate the potential of termino-lateral nerve repair to original and adjacent nerves. In experimental group 1, the peroneal nerve was sectioned and then attached to the posterior tibial nerve in a termino-lateral fashion. In experiment group 2, the motor nerves to the gastrocnemius muscle were sectioned and then attached to the posterior tibial nerve in a termino-lateral fashion. In experimental group 3, the obturator nerve (L2-4) was sectioned and attached to the sciatic nerve (L4-6) in a termino-lateral fashion. For the control in each group, the same type of nerve used in each respective group was transected without repair. Experimental groups 1 and 2 showed viable axons in the peroneal nerve distal to the neurorrhaphy site. Experimental group 3 showed no viable axons at these sites. No regeneration was observed in the transected nerve without repair in all three control groups. This study suggests that termino-lateral neurorrhaphy is a viable means of repairing damaged nerves if the distal segment of the sectioned nerve is reattached to its original trunk distal to its original branch point. However, the results from experimental group 3 demonstrate that termino-lateral neurorrhaphy cannot be used to repair nerves when the donor and recipient nerves originate from different spinal cord levels.

Nerve regeneration after terminolateral neurorrhaphy: experimental study in rats.

Four methods of nerve terminolateral neurorrhaphy (TLN) were studied in rat experimental model. In Group A, the distal end of a severed peroneal nerve was sutured end-to-side with an intact tibial nerve trunk, without removal of the tibial epineurium at the suture site. In Group B, the distal end of a severed peroneal nerve was sutured end-to-side with the intact tibial nerve trunk, with removal of the tibial epineurium at the suture site. In Group C, a nerve segment was bridged between the distal part of the severed peroneal nerve and the intact tibial nerve with two end-to-side sutures. In Group D, the proximal end of a severed tibial nerve was sutured end-to-side with the peroneal nerve trunk. Through electrophysiologic, histologic, and ultrastructural examinations, the following conclusions were drawn: 1. Nerve regeneration is possible after TLN. 2. The regenerating fibers after TLN have the ability to penetrate the endoneurium, perineurium, and epineurium. 3. After different methods of TLN, the regenerating fibers grow in both a flowing-out and a filling-in fashion.

End-to-Side Neurorrhaphy with Removal of the Epineurial Sheath

Terminolateral neurorrhaphies were used up to the beginning of this century. After that, they were no longer reported. We tested the efficacy of a new type of end-to-side neurorrhaphy. A group of 20 rats had the peroneal nerve sectioned, and the distal ending was sutured to the lateral face of the tibial nerve after removing a small epineural window. All experiments were made on the right side, the left one remaining untouched in half the animals of each group. The other half was denervated by sectioning and inverting the endings of the peroneal nerves. In this way, tibial cranial muscles were either normal or denervated on the left side and reinnervated through end-to-side neurorrhaphies on the right side. After 7.8 months, the animals were subjected to electrophysiologic tests, sacrificed, and the nerves and muscles were taken for histologic examination. A response of the tibial cranial muscle was obtained in 90 percent of the animals. The distal ending of the peroneal nerve showed an average of 861 nerve fibers. The average areas of the reinnervated tibial cranial muscles were (microns 2) 1617.81 for M2n (when the contralateral side was normal) and 1579.19 for M2d (when the contralateral was denervated). We conclude that the terminolateral neurorrhaphy is functional, conducting electrical stimuli and allowing the passage of axons from the lateral surface of a healthy nerve, to reconstitute the distal segment of a sectioned nerve. The absence of an incision on the axons of the donor nerve was no impediment to axonal regeneration or to the passage of electrical stimuli. The results demonstrate the possibility of using end-to-side and terminolateral neurorrhaphies for reconstituting neural lesions when only a distal end is available; the reinnervation can be obtained from the lateral face of a healthy nerve.