Nerve Transfer

Abstract: A novel method for the control of a myoelectric upper limb prosthesis was achieved in a patient with bilateral amputations at the shoulder disarticulation level Four independently controlled nerve-muscle units were created by surgically anastomosing residual brachial plexus nerves to dissected and divided aspects of the pectoralis major and minor muscles The musculocutaneous nerve was anastomosed to the upper pectoralis major; the median nerve was transferred to the middle pectoralis major region; the radial nerve was anastomosed to the lower pectoralis major region; and the ulnar nerve was transferred to the pectoralis minor muscle which was moved out to the lateral chest wall After five months, three nerve-muscle units were successful (the musculocutaneous, median and radial nerves) in that a contraction could be seen, felt and a surface electromyogram (EMG) could be recorded Sensory reinnervation also occurred on the chest in an area where the subcutaneous fat was removed The patient was fitted with a new myoelectric prosthesis using the targeted muscle reinnervation The patient could simultaneously control two degrees-of-freedom with the experimental prosthesis, the elbow and either the terminal device or wrist Objective testing showed a doubling of blocks moved with a box and blocks test and a 26% increase in speed with a clothes pin moving test Subjectively the patient clearly preferred the new prosthesis He reported that it was easier and faster to use, and felt more natural

Abstract: Objective Although the rate of reported facial nerve preservation after surgery for vestibular schwannomas continuously increases, facial nerve paresis or paralysis is a frequent postsurgical sequelae of major concern The major goal of this study was to define criteria for the right indication, timing, and type of therapy for patients with palsies despite anatomic nerve continuity and those with loss of anatomic continuity Methods One thousand vestibular schwannomas were surgically treated at the Department of Neurosurgery at Nordstadt Hospital from 1978 to 1993 Of 979 cases of complete removal and 21 cases of deliberately partial removal, the facial nerve was anatomically preserved in 929 cases (93%) The rate of preservation is increasing, as is evidenced in the most recent cases, and preservation is supported by special electrophysiological monitoring The facial nerve was anatomically severed in 60 cases (6%) It was anatomically lost in previous operations that were performed elsewhere in 11 cases (1%) In case of nerve discontinuity (42 cases), immediate nerve reconstruction by one of three available intracranial procedures (within the cerebellopontine angle, intracranial-intratemporal, intracranial-extracranial) was performed in the same surgical setting In case of loss of the proximal facial nerve stump at the brain stem, early reanimation by combination with the hypoglossal nerve was achieved in most patients within weeks after tumor surgery In a few patients with anatomic nerve continuity but absence of reinnervation for 10 to 12 months, a hypoglossal-facial combination was applied All the patients with partial or with complete palsies were treated in a special follow-up program of regular controls and of modulation of physiotherapeutic treatment every 3 to 6 months Results In intracranial nerve reconstruction at the cerebellopontine angle, 61 to 70% of patients regained complete eye closure and an overall result equivalent to House-Brackmann Grade 3 Hypoglossal-facial reanimation led to Grade 3 in 79% The duration between the onset of paralysis and the reconstructive procedure is decisive for the quality of the outcome These data are discussed in view of other treatment options and certain parameters influencing outcome Conclusions This management contains three major principles as follows: 1) preservation of facial nerve continuity in function by the aid of intraoperative monitoring, 2) early nerve reconstruction in case of lost continuity, and 3) scheduled follow-up program for all patients with incomplete or complete palsies

Abstract: Purpose: This study reports the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps. Methods: Seven patients with an average age of 25 years with loss of shoulder abduction secondary to upper brachial plexus injuries had nerve transfer using the nerve to the long head of the triceps to the anterior branch(es) of the axillary nerve through the posterior approach. The spinal accessory nerve was used simultaneously for nerve transfer to the suprascapular nerve. The follow-up period ranged from 18 to 28 months (average, 20 mo). Results: All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124°. No notable weakness of elbow extension was observed. Conclusions: This method is a reliable and effective procedure for deltoid reconstruction in brachial plexus injury (upper-arm type) and should be combined with spinal accessory nerve transfer to the suprascapular nerve to obtain good shoulder abduction.