BACKGROUND: Upper limb spasticity is a surgical challenge, both in diminishing agonists spasticity and reconstructing antagonist function. Brachioradialis (BR) is often involved in elbow flexors spasticity. Finger extension is often impaired in spastic patients. This study aims to demonstrate the feasibility of BR motor branch to posterior interosseous nerve (PIN) during BR selective neurectomies, and to describe fascicles topography inside the radial nerve to facilitate PIN dissection.
METHODS: Ten upper limbs from 10 fresh frozen anatomical specimens were dissected. Motor branches to the BR, wrist extensors, supinator, PIN and radial sensory branch were identified. BR to PIN transfer was realized and its feasibility was studies (donor length, tensionless suture).
RESULTS: BR to PIN transfer was achievable in 9 out of 10 cases. The position of the sensory branch of the radial nerve was inferior or medial in all cases. The position of the PIN was lateral in 90% of the cases.
CONCLUSIONS: BR to PIN nerve transfer is achievable in most cases (90%). The lateral topography of the PIN and the inferomedial topography of the sensory branch in most cases allows for an easier intraoperative finding of the PIN when stimulation is not possible.
UNASSIGNED: IV, feasibility study.

\"State of the Art\" Learning Objectives: This manuscript serves to provide the reader with a general overview of the contemporary approaches to peripheral nerve reconstruction as the field has undergone considerable advancement over the last 3 decades. The learning objectives are as follows: To provide the reader with a brief history of peripheral nerve surgery and some of the landmark developments that allow for current peripheral nerve care practices.To outline the considerations and management options for the care of patients with brachial plexopathy, spinal cord injury, and lower extremity peripheral nerve injury.Highlight contemporary surgical techniques to address terminal neuroma and phantom limb pain.Review progressive and future procedures in peripheral nerve care, such as supercharge end-to-side nerve transfers.Discuss rehabilitation techniques for peripheral nerve care.
Le présent manuscrit vise à fournir au lecteur un aperçu général des approches contemporaines de la reconstruction des nerfs périphériques puisque le domaine a beaucoup progressé depuis trois décennies. Les objectifs d’apprentissage s”établissent comme suit : Fournir au lecteur un bref historique de la chirurgie des nerfs périphériques et quelques-unes des avancées historiques qui ont donné lieu aux pratiques de soins actuelles des nerfs périphériques.Décrire les considérations et les possibilités de prise en charge pour les soins des patients ayant une plexopathie brachiale, une lésion médullaire ou une lésion des nerfs périphériques des membres inférieurs.Souligner les techniques chirurgicales contemporaines pour traiter les neurones terminaux et les douleurs des membres fantômes.Examiner les interventions progressives et futures pour les soins des nerfs périphériques, comme l’amplification du transfert du nerf terminal au nerf latéral.Parler des techniques de réadaptation pour les soins des nerfs périphériques.

Introduction: Upper limb function loss in cervical spinal cord injury (SCI) contributes to substantial disability, and negatively impacts quality of life. Nerve transfer and tendon transfer surgery can provide improved upper limb function. This study assessed the utilization of nerve and tendon transfer surgery for individuals with tetraplegia in Canada. Methods: Data from the Canadian Institute for Health Information\'s Discharge Abstracts Database and the National Ambulatory Care Reporting System were used to identify the nerve and tendon transfer procedures performed in individuals with tetraplegia (2004-2020). Cases were identified using cervical SCI ICD-10-CA codes and Canadian Classification of Intervention codes for upper extremity nerve and tendon transfers. Data on sex, age at time of procedure, province, and hospital stay duration were recorded. Results: From 2004 to 2020, there were ≤80 nerve transfer procedures (81% male, mean age 38.3 years) and 61 tendon transfer procedures (78% male, mean age 45.0 years) performed (highest in Ontario and British Columbia). Using an estimate of 50% eligibility, an average of 1.3% of individuals underwent nerve transfer and 1.0% underwent tendon transfer. Nerve transfers increased over time (2004-2009, n = <5; 2010-2015, n = 27; 2016-2019, n = 49) and tendon transfers remained relatively constant. Both transfer types were performed as day-surgery or single night stay. Conclusions: Nerve and tendon transfer surgery to improve upper limb function in Canadians with tetraplegia remains low. This study highlights a substantial gap in care for this vulnerable population. Identification of barriers that prevent access to care is required to promote best practice for upper extremity care.
Introduction : La perte de fonction du membre supérieur en cas de lésion de la moelle épinière cervicale (SCI0 contribue à un handicap substantiel avec des répercussions négatives sur la qualité de vie. La chirurgie de transfert des nerfs et des tendons peut apporter une amélioration du fonctionnement du membre supérieur. Cette étude a évalué l\'utilisation de la chirurgie de transfert de nerfs et de tendons pour les patients tétraplégiques au Canada. Méthodes : Des données issues de la base de données des résumés de congés de l\'Institut canadien d\'information sur la santé du système national d\'information sur les soins ambulatoires ont été utilisées pour identifier les procédures de transfert de nerfs et de tendons pratiquées sur des patients tétraplégiques entre 2004 et 2020. Les cas ont été identifiés en utilisant les codes de SCI cervicales du CIM-10-CA et des codes canadiens de classification des interventions pour les transferts de nerfs et de tendons du membre supérieur. Les données sur le sexe et l\'âge au moment de la procédure, la province et la durée de séjour à l\'hôpital ont été consignées. Résultats : Entre 2004 et 2020, il y a eu ≤ 80 procédures de transferts de nerfs (hommes : 81 %, âge moyen : 38,3 ans) et 61 procédures de transfert de tendons (hommes : 78 %, âge moyen : 45,0 ans) pratiquées (principalement en Ontario et en Colombie-Britannique). En estimant une admissibilité de 50 %, une moyenne de 1,3 % des patients a subi un transfert de nerfs et 1,0 % des patients a subi un transfert tendineux. Les transferts de nerfs ont augmenté au fil des années (2004-2009, n = < 5; 2010-2015, n = 27; 2016-2019, n = 49) tandis que le nombre de transferts tendineux est resté relativement stable. Les deux types de transferts ont été pratiqués das le cadre de la chirurgie d\'un jour ou avec une hospitalisation d\'une seule nuit. Conclusions : La chirurgie de transfert de nerfs et de tendons pour l\'amélioration des fonctions des membres supérieurs reste peu utilisée pour les Canadiens tétraplégiques. Cette étude souligne une lacune substantielle des soins pour cette population vulnérable. Il est nécessaire d\'identifier les obstacles qui empêchent l\'accès aux soins afin de promouvoir une meilleure pratique pour les soins du membre supérieur.

OBJECTIVE: Cervical spinal cord injury (SCI) and lower trunk brachial plexus injury (BPI) commonly result in hand paralysis. Although restoring hand function is complex and challenging to achieve, regaining volitional hand control drastically enhances functionality for these patients. The authors aimed to systematically review the outcomes of hand-opening function after supinator to posterior interosseous nerve (PIN) transfer.
METHODS: A systematic literature review was performed according to the PRISMA guidelines.
RESULTS: A total of 16 studies with 88 patients and 119 supinator to PIN transfers were included (87 transfers for SCI and 32 for BPI). In most studies, the time interval from injury to surgery was 6-12 months. Finger extension and thumb extension (Medical Research Council grade ≥ 3/5) recovered in 86.5% (103/119) and 78.1% (93/119) of cases, respectively, over a median follow-up of 19 months. The rates of recovery were similar for the SCI and BPI populations (finger extension, 87.3% in SCI and 84.3% in BPI; thumb extension, 75.8% in SCI and 84.3% in BPI). Type of injury (OR 1.05, 95% CI 0.17-6.4, p = 0.95), time from injury to surgery (OR 1.01, 95% CI 0.8-1.29, p = 0.88), and age (OR 0.97, 95% CI 0.90-1.06, p = 0.60) were not associated with odds of a successful outcome. Duration of follow-up was significantly associated with successful finger extension (OR 1.15, 95% CI 1.01-1.30, p = 0.026). No donor-associated supinator weakness was reported postoperatively given that patients had an intact bicep muscle preoperatively contributing to supination.
CONCLUSIONS: Supinator to PIN transfer is a safe and effective procedure that can achieve successful restoration of digital extension in the SCI and BPI population at similar rates. Duration of follow-up was associated with superior outcomes, which was expected.

BACKGROUND: Lower eyelid suspension, a common therapeutic procedure for facial paralysis-induced eyelid retraction, faces challenges due to high recurrence in patients lacking facial muscle function and impedes wider adoption. This research aims to explore the potential effects of restoring orbicularis oculi muscle tension through facial nerve reanimation prior to lower eyelid suspension and to define the indications for lower eyelid suspension.
METHODS: The study encompassed 32 individuals with complete facial paralysis, segmented into group A (reanimation group) and group B (non-reanimation group), based on whether the orbicularis oculi muscle\'s tension was restored through facial nerve reconstruction prior to lower eyelid suspension. Subjective assessments of eyelid closure (the inter-eyelid gap upon gentle closure) and objective methods measures of scleral show (the distance from the pupil\'s center to the lower eyelid margin, MRD2) were used to provide a comprehensive analysis of long-term effectiveness.
RESULTS: The group A exhibited significantly greater long-term improvement in lagophthalmos and lower eyelid ectropion. The alterations in MRD2 measured 2.66 ± 0.27 mm in the group A versus 2.08 ± 0.53 mm in the group B, denoting a statistically significant variance (p < 0.001). Moreover, while the ratio of MRD2 preoperative 6 months postoperative revealed no significant difference between groups, a significant difference emerged in 12 months postoperative (group A: 1.02 ± 0.21; group B: 1.18 ± 0.24; p < 0.05), with the values in group A closer to 1, indicative of enhanced symmetry.
CONCLUSIONS: Restoring the tension in the orbicularis oculi muscle through facial nerve reconstruction prior to palmaris longus tendon sling could effectively sustain long-term outcomes of lower eyelid retraction correction and reduce the recurrence rate.
METHODS: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: Traumatic high cervical spinal cord injury (SCI) can result in a devastating loss of functional respiration, leaving patients permanently dependent on mechanical ventilation. Nerve transfer is a promising reinnervation strategy that has the potential to restore connectivity in paralyzed distal muscles. The spinal accessory nerve (SAN) remains functional in most cases after high cervical SCI and can serve as a donor to reinnervate the phrenic nerve (PN), thereby improving diaphragmatic function.
METHODS: Information regarding thorough physical, electrodiagnostic, and pulmonary assessments to establish candidacy for nerve transfer, as well as the surgical procedure, was summarized with an illustrative case. The patient demonstrated improvement in pulmonary function testing but did not achieve independent respiration. A systematic literature review identified 3 studies with 9 additional patients who had undergone SAN-to-PN transfer. The nerve transfer meaningfully restored diaphragmatic function, improving pulmonary function tests and reducing ventilator dependency.
CONCLUSIONS: Respiratory dependency significantly impacts the quality of life of patients with a high cervical SCI. The use of the lower SAN motor branch for PN transfer is safe and does not result in a meaningful downgrade in trapezius function. Outcomes following this procedure are promising but heterogeneous, indicating a need for significant innovation and improvement for future therapies. https://thejns.org/doi/10.3171/CASE24236.

BACKGROUND: Facial reanimation procedures are used in the treatment of the disorder that impairs mimetic function and jeopardizes physical and psychological health, and one of the most important instruments of these techniques is the masseteric neurovascular bundle (NVB) and proper identification at the mandibular notch level. In the current study, a triangular area (deep masseteric triangle, DMT) on the lateral surface of the masseter muscle that was identified to help reliable determination of the masseteric NVB at the mandibular notch level.
METHODS: 40 parotideomasseteric region dissections were performed in 10 female and 10 male donated cadavers. Structures lateral to the masseter muscle were removed. The edge length of the masseter muscle on the zygomatic arch side was measured. After the edges of the DMT were measured, the masseteric NVB was found by dissection and its distance (depth) from the skin line was measured.
RESULTS: The mean lengths of the superior, posterior, and anterior margins were 17.3 (±4.5) mm, 25.9 (±6.2) mm, and 26.3 (±6.5) mm, respectively. The total length of the upper edge of the masseteric muscle attached to the zygomatic arch averaged 52.7 (±5.2) mm. The masseteric neurovascular bundle was detected at a depth of approximately 17 mm from the skin of the parotideamasseteric region.
CONCLUSIONS: The visualization of the DMT can be used as an important landmark for access to branch-free part of the masseteric nerve. Moreover, an specific approach for masseteric NVB localization can be established by drawing a line between the mandibular angle and the midpoint of the upper edge of the DMT. This technique can greatly improve the accuracy of both masseteric nerve harvesting and masseteric nerve block procedures.

OBJECTIVE: Sensory nerve transfers may be performed to restore protective sensation and tactile perception after peripheral nerve injury in the upper extremity. There is a paucity of literature on the available donor-recipient configurations for sensory nerve transfers. This article presents a systematic review of reported sensory nerve transfers in the upper extremity.
METHODS: Original articles published between 1982 and 2022 were searched in MEDLINE and EMBASE. Articles describing a sensory nerve transfer were included if patient sensory outcomes were reported. Outcomes were categorized according to the modified British Medical Research Council scale, with an outcome of S3 or better defined as satisfactory.
RESULTS: Of 1,049 articles, 39 met inclusion and quality criteria. Twenty-seven articles were primary research studies reporting on 197 patients who underwent 11 unique nondigital sensory donor nerve transfers and 24 unique digital donor nerve transfer procedures. The most reliable recipient nerve for restoring sensation to the ulnar border of the small finger was proper ulnar digital nerve of the small finger (38 patients, 89% satisfactory sensory outcome). The best available donors for transfer into the proper ulnar digital nerve of the small finger were proper ulnar digital nerve of the long finger (16 patients, 87.5% good sensory outcome) and palmar cutaneous branch of the median nerve (15 patients, 100% good sensory outcome). To restore sensation along the ulnar border of the thumb and radial aspect of the index finger, the best available donor was the superficial branch of the radial nerve, regardless of transfer into common digital nerve 1 (38 patients, success rate 63%) or directly to proper ulnar digital nerve of the thumb or proper radial digital nerve of the index finger (nine patients, success rates 67%).
CONCLUSIONS: Outcomes after sensory nerve transfers are generally good. Surgeons should transfer into a digital nerve recipient when attempting to reconstruct sensation.
METHODS: Therapeutic IV.

Lower motor neuron (LMN) damage results in denervation of the associated muscle targets and is a significant yet under-appreciated component of spinal cord injury (SCI). Denervated muscle undergoes a progressive degeneration and fibro-fatty infiltration that eventually renders the muscle non-viable unless reinnervated within a limited time window. The distal nerve deprived of axons also undergoes degeneration and fibrosis making it less receptive to axons. In this review, we describe the LMN injury associated with SCI and its clinical consequences. The process of degeneration of the muscle and nerve is broken down into the primary components of the neuromuscular circuit and reviewed, including the nerve and Schwann cells, the neuromuscular junction, and the muscle. Finally, we discuss three promising strategies to reverse denervation atrophy. These include providing surrogate axons from local sources; introducing stem cell-derived spinal motor neurons into the nerve to provide the missing axons; and finally, instituting a training program of high-energy electrical stimulation to directly rehabilitate these muscles. Successful interventions for denervation atrophy would significantly expand reconstructive options for cervical SCI and could be transformative for the predominantly LMN injuries of the conus medullaris and cauda equina.

暂无摘要。