INTRODUCTION: Nerve grafting with the sural nerve is a standard treatment method for radial nerve injury that requires another incision at the lateral ankle distal from the injured upper limb. The aim of this study was to investigate the common trunk (CTCB) of the inferior lateral brachial cutaneous nerve (ILBCN) and posterior antebrachial cutaneous nerve (PACN) as a possible donor inside the lateral intermuscular septum. MATERIALS AND METHODS: The arms and legs of 8 formalin-embalmed cadaver specimens were studied. The radial nerve, common trunk of the ILBCN and PACN, and the sural nerve were identified and measured in length and diameter. For histological examination, nerve samples from 6 fresh cadavers were harvested and processed for further axonal counting. RESULTS: The average length of the CTCB was 114.92 ± 18.9 mm. To match the diameter of the radial nerve at its proximal third, 3 cables of CTCB graft were necessary, which corresponds to a defect length of 3.8 cm. At the level of the distal third, the number of grafts was reduced to 2 with a corresponding defect length of 5.7 cm. The radial nerve contained 15162 ± 318 axons, and the CTCB comprised 3959 ± 176 axons. To match the axon count of the recipient nerve, 4 grafts of CTCB were necessary, which corresponded to a defect length of 2.8 cm. CONCLUSION: CTCB is a consistent and easily dissected cutaneous nerve branch of the radial nerve that can be used for bridging small gaps after neuroma-in-continuity in radial nerve palsy.
- MeSH
- Middle Aged MeSH
- Humans MeSH
- Cadaver MeSH
- Nerve Transfer * methods MeSH
- Radial Nerve * surgery anatomy & histology injuries MeSH
- Sural Nerve * transplantation anatomy & histology MeSH
- Aged MeSH
- Plastic Surgery Procedures * methods MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- MeSH
- Humans MeSH
- Microsurgery * methods MeSH
- Nerve Transfer methods MeSH
- Infant, Newborn MeSH
- Neonatal Brachial Plexus Palsy * surgery MeSH
- Check Tag
- Humans MeSH
- Infant, Newborn MeSH
- Publication type
- Review MeSH
BACKGROUND: The recovery of the spontaneous smile has become a primary focus in facial reanimation surgery and its major determinant is the selected neurotizer. We aimed to compare the spontaneity outcomes of the most preferred neurotization methods in free functional muscle transfer for long-standing facial paralysis. METHODS: The Embase, Ovid Medline, and PubMed databases were queried with 21 keywords. All clinical studies from the last 20 years reporting the postoperative spontaneity rate for specified neurotization strategies [cross-face nerve graft (CFNG), contralateral facial nerve (CLFN), motor nerve to the masseter (MNM), and dual innervation (DI)] were included. A meta-analysis of prevalence was performed using Freeman-Tukey double arcsine transformation, I2 statistic, and generic inverse variance with a random-effects model. Risk Of Bias In Non-randomized Studies of Interventions and Newcastle-Ottawa scale were used to assess bias and study quality. RESULTS: The literature search produced 2613 results and 473 unique citations for facial reanimation. Twenty-nine studies including 2046 patients were included in the systematic review. A meta-analysis of eligible data (1952 observations from 23 studies) showed statistically significant differences between the groups (CFNG: 0.94; 95% confidence interval [CI], 0.76-1.00, CLFN: 0.91; 95% CI, 0.49-1.00, MNM: 0.26; 95% CI, 0.05-0.54, DI: 0.98; 95% CI, 0.90-1.00, P < 0.001). In pairwise comparisons, statistically significant differences were found between MNM and other neurotization strategies (P < 0.001 in CFNG compared with MNM, P = 0.013 for CLFN compared with MNM, P < 0.001 for DI compared with MNM). CONCLUSIONS: DI- and CLFN-driven strategies achieved the most promising outcomes, whereas MNM showed the potential to elicit spontaneous smile at a lower extent. Our meta-analysis was limited primarily by incongruency between spontaneity assessment systems. Consensus on a standardized tool would enable more effective comparisons of the outcomes.
- MeSH
- Facial Paralysis * surgery MeSH
- Humans MeSH
- Masseter Muscle innervation MeSH
- Nerve Transfer * methods MeSH
- Facial Nerve surgery MeSH
- Smiling physiology MeSH
- Facial Expression MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Meta-Analysis MeSH
- Systematic Review MeSH
Extrakce zubů moudrosti, zejména hlouběji retinovaných nebo v intimním kontaktu s dolním alveolárním nervem, jsou zatíženy komplikací ve smyslu poranění tohoto nervu. Snahou lékaře je odstranit příčinu obtíží pacienta, jímž je myšlen problematický zub moudrosti, a zároveň nepřivodit nepříjemné komplikace nemocnému. Za tímto účelem jsou využívány stále dokonalejší zobrazovací metody a pokročilé chirurgické techniky. Občas se i při největší snaze ošetřujícího lékaře nevyhneme poranění nervu, ale i v nejtěžším případě poranění, jako je transsekce s defektem nervu, je možné komplikaci s velmi vysokým procentem úspěšnosti řešit a pacienta vyléčit. V tomto příspěvku prezentujeme kazuistiku pacientky léčené na naší klinice, u které došlo k traumatické lézi dolního alveolárního nervu během transalveolární extrakce zubu 48, a popisujeme následnou úspěšnou rekonstrukci pomocí štěpu z nervus suralis.
Extractions of wisdom teeth, especially those that are deeply impacted or in intimate contact with the lower alveolar nerve, are fraught with complications in the sense of injury to that nerve. The doctor‘s effort is to eliminate the cause of the patient‘s difficulties, which is the problematic wisdom tooth, and at the same time not causing unpleasant complications for the patient. For this purpose, increasingly sophisticated imaging techniques and advanced surgical techniques are used. Sometimes, even with the best efforts of the attending physician, nerve injury cannot be avoided, but even in the most severe case of injury, such as a transsection with a nerve defect, it is possible to solve the complication with a very high percentage of success and cure the patient. In this paper, we present the case report of a patient treated in our clinic who suffered a traumatic lesion of the lower alveolar nerve during the transalveolar extraction of tooth 48 and describe the subsequent successful reconstruction using a graft from the sural nerve.
- MeSH
- Toothache surgery MeSH
- Adult MeSH
- Tooth Extraction methods MeSH
- Iatrogenic Disease MeSH
- Humans MeSH
- Molar, Third surgery pathology MeSH
- Nerve Transfer methods MeSH
- Mandibular Nerve Injuries * surgery MeSH
- Tooth, Impacted * surgery MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
- Examination Questions MeSH
OBJECTIVES: To investigate the anatomical feasibility of the infraspinatus branch of the suprascapular nerve (IB-SSN) reconstruction by lower subscapular nerve (LSN) transfer. METHODS: The morphological study was performed on 18 adult human cadavers. The length of the distal stump of the IB-SSN, the length of the LSN available for reconstruction and diameter of both stumps were measured. The feasibility study of the LSN to IB-SSN transfer was performed. RESULTS: The mean length of the IB-SSN to the end of its first branch was 40.9 mm (±4.6). Its mean diameter was 2.3 mm (±0.3). The mean length of the LSN stump, which was mobilized from its original course and transferred to reach the distal stump of the IB-SSN was 66.5 mm (±11.8). Its mean diameter was 2.1 mm (±0.3). The mean ratio between LSN and IB-SSN diameters was 0.9 (±0.1). The nerve transfer was feasible in 17 out of 18 cases (94.4%). CONCLUSION: This study demonstrates that direct LSN to IB-SSN transfer is anatomically feasible in most cases in the adult population. It may be used in cases of complex scapular fractures resulting in severe suprascapular nerve injury.
- MeSH
- Adult MeSH
- Humans MeSH
- Nerve Transfer * methods MeSH
- Brachial Plexus * surgery MeSH
- Nerve Regeneration physiology MeSH
- Rotator Cuff MeSH
- Feasibility Studies MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Publication type
- Journal Article MeSH
Restoring shoulder abduction is one of the main priorities in the surgical treatment of brachial plexus injuries. Double nerve transfer to the axillary nerve and suprascapular nerve is widely used and considered the best option. The most common donor nerve for the suprascapular nerve is the spinal accessory nerve. However, donor nerves for axillary nerve reconstructions vary and it is still unclear which donor nerve has the best outcome. The aim of this study was to perform a systematic review on reconstructions of suprascapular and axillary nerves and to perform a meta-analysis investigating the outcomes of different donor nerves on axillary nerve reconstructions. We conducted a systematic search of English literature from March 2001 to December 2020 following PRISMA guidelines. Two outcomes were assessed, abduction strength using the Medical Research Council (MRC) scale and range of motion (ROM). Twenty-two studies describing the use of donor nerves met the inclusion criteria for the systematic review. Donor nerves investigated included the radial nerve, intercostal nerves, medial pectoral nerve, ulnar nerve fascicle, median nerve fascicle and the lower subscapular nerve. Fifteen studies that investigated the radial and intercostal nerves met the inclusion criteria for a meta-analysis. We found no statistically significant difference between either of these nerves in the abduction strength according to MRC score (radial nerve 3.66 ± 1.02 vs intercostal nerves 3.48 ± 0.64, p = 0.086). However, the difference in ROM was statistically significant (radial nerve 106.33 ± 39.01 vs. intercostal nerve 80.42 ± 24.9, p < 0.001). Our findings support using a branch of the radial nerve for the triceps muscle as a donor for axillary nerve reconstruction when possible. Intercostal nerves can be used in cases of total brachial plexus injury or involvement of the C7 root or posterior fascicle. Other promising methods need to be studied more thoroughly in order to validate and compare their results with the more commonly used methods.
- MeSH
- Humans MeSH
- Nerve Transfer * methods MeSH
- Accessory Nerve surgery MeSH
- Brachial Plexus Neuropathies * surgery MeSH
- Brachial Plexus * injuries surgery MeSH
- Shoulder innervation surgery MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Meta-Analysis MeSH
- Review MeSH
- Systematic Review MeSH
BACKGROUND: Contrary to the classic anatomical description, many recent studies have reported wide variations in branching patterns and location of motor branches that are supplying the pronator teres muscle. To understand these variations and their implications in surgical procedures of the nerve transfers, a systematic review was performed on the innervation of pronator teres muscle from cadaveric studies. METHODS: A systematic literature search was performed in databases such as Medline, PubMed, Google Scholar, SciELO, ScienceDirect, Cochrane reviews and orthopedics textbooks using the search terms "pronator teres nerve branches"; AND "number" OR "location" OR "length" OR "diameter" yielded 545 article links. Articles were evaluated according to PRISMA guidelines. RESULTS: A total of twenty cadaveric studies including 648 branches have registered 52.9% of two branch innervation pattern followed by 31.3%-single branch pattern; 13.5%-three branch pattern; 1.7%-four branch pattern, and 0.4%-five branch patterns, respectively. Of the 403 branches studied for their location in relation with the humeral intercondylar line, most branches were located distal to the line (50.3%), followed by 32.7% (proximal to it) and 16.8% at the line, respectively. The distance of branches located proximal and distal to humeral intercondylar line was in the range of 1.25-10 cm, and 1.1-7.5 cm, respectively. The mean length and diameter of nerves reported were 4.37 ± 2.43 cm, and 1.5 mm, respectively. CONCLUSIONS: Our data defined the morphometrics of nerve branches and they often met the required diameter for neurotization procedures. Our findings also demonstrated that the morphometrics, branching pattern and their location vary between populations and this information is very vital for surgeons during the nerve transfers.
- MeSH
- Anatomic Variation * MeSH
- Muscle, Skeletal innervation MeSH
- Humans MeSH
- Cadaver MeSH
- Nerve Transfer methods MeSH
- Median Nerve anatomy & histology MeSH
- Ulnar Nerve anatomy & histology MeSH
- Forearm innervation MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Systematic Review MeSH
Cíl: Neurotrofická keratopatie (NK) je degenerativní onemocnění rohovky způsobené poškozením trigeminální inervace vedoucí ke snížení citlivosti rohovky až k její úplné anestezii. Porucha rohovkové inervace vede k morfologickým a metabolickým poruchám epitelu a k rozvoji recidivujících nebo perzistujících defektů epitelu až vředů rohovky, které mohou progredovat ve stromální lýzu a perforaci rohovky. Jednou z možností řešení těžké neurotrofické keratopatie je reinervace anestetické rohovky s využitím n. supraorbitalis a autologního štěpu senzitivního nervu (nepřímá neurotizace). V práci prezentujeme výsledky léčby pomocí této metody u pacienta s perzistujícím epiteliálním defektem a vředem rohovky po úrazu oka v terénu denervované rohovky. Výsledky: 22letý muž s anamnézou neurochirurgického zákroku pro astrocytom mozečku a kmene vpravo ve 2 letech věku byl od dětství sledován pro pooperační parézu n. facialis vpravo s lagoftalmem, současně byla přítomna porucha funkce n. trigeminus vpravo. Ve 22 letech po kontuzi pravého bulbu došlo k rozvoji perzistujícího epiteliálního defektu a následně vředu rohovky. Vzhledem k vyčerpání jiných terapeutických možností byla u pacienta provedena reinervace rohovky vpravo cestou kontralaterálního n. supraorbitalis s využitím autologního štěpu z n. suralis z pravé dolní končetiny. 5 měsíců po výkonu došlo k částečné obnově citlivosti rohovky. Po následné transplantaci amniové membrány do chronického defektu epitelu se rozsáhlý epiteliální defekt uzavřel a došlo k projasnění zkaleného stromatu rohovky. Závěr: Technika reinervace anestetické rohovky s využitím n. supraorbitalis a autologního štěpu senzitivního nervu představuje novou možnost řešení těžké formy neurotrofické keratopatie. U pacienta z naší kazuistiky operovaného touto metodou došlo po výkonu ke zhojení těžkého rohovkového nálezu.
Purpose: Neurotrophic keratopathy (NK) is a degenerative corneal disease caused by damage to the trigeminal innervation due to a decrease in corneal sensitivity or complete anaesthesia. Impaired corneal innervation leads to morphological and metabolic disorders of the epithelium. In addition, it also leads to the development of recurrent or persistent epithelial defects in corneal ulcers, which may progress to stromal lysis and corneal perforation. One possible solution for severe NK is reinnervation of the anaesthetic cornea (corneal neurotization) using the supraorbital nerve and an autologous sensory nerve graft (indirect neurotization). This article presents the results of corneal neurotization in a young male patient with persistent epithelial defects and corneal ulcers due to corneal denervation. Results: A 22-year-old man with a history of neurosurgery for astrocytoma of the cerebellum and trunk on the right side at the age of 2 years, was observed for postoperative paresis of the right facial nerve with lagophthalmos in his childhood. The presence of asymptomatic dysfunction of the right trigeminal nerve was also noted. At the age of 22 years, after right eyeball contusion, the vision of the right eye decreased and a persistent epithelial defect developed, followed by corneal ulceration. Due to the exhaustion of therapeutic options in a young patient with corneal anaesthesia, the cornea was reinnervated via the contralateral supraorbital nerve using an autologous sural nerve graft. Five months after the surgery, the sensitivity of the cornea of the right eye began to recover. After amniotic membrane transplantation, the extensive epithelial defect healed, and the opaque corneal stroma gradually cleared up. Conclusion: The reinnervation of the anaesthetic cornea (corneal neurotization) using the supraorbital nerve and the autologous sensory nerve graft represents a new solution for severe NK treatment. The severe corneal condition in our patient healed after the surgery.
- Keywords
- neurotrofická keratopatie, neurotizace rohovky,
- MeSH
- Keratitis, Dendritic surgery etiology physiopathology MeSH
- Humans MeSH
- Young Adult MeSH
- Corneal Diseases * surgery etiology physiopathology MeSH
- Nerve Transfer methods MeSH
- Nerve Regeneration MeSH
- Epithelium, Corneal physiopathology MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Young Adult MeSH
- Male MeSH
- Publication type
- Case Reports MeSH
BACKGROUND: The potential to utilize the lower subscapular nerve for brachial plexus surgery has been suggested in many anatomical studies. However, we know of no studies in the literature describing the use of the lower subscapular nerve for axillary nerve reconstruction to date. This study aimed to examine the effectiveness of this nerve transfer in patients with upper brachial plexus palsy. METHODS: Of 1340 nerve reconstructions in 568 patients with brachial plexus injury performed by the senior author (P.H.), a subset of 18 patients underwent axillary nerve reconstruction using the lower subscapular nerve and constitutes the patient group for this study. The median age was 48 years, and the median time between trauma and surgery was 6 months. A concomitant radial nerve injury was found in 8 patients. RESULTS: Thirteen patients completed a minimum follow-up period of 24 months. Successful deltoid recovery was defined as (1) muscle strength MRC grade ≥ 3, (2) electromyographic signs of reinnervation, and (3) increase in deltoid muscle mass. Axillary nerve reconstruction was successful in 9 of 13 patients, which represents a success rate of 69.2%. No significant postoperative weakness of shoulder internal rotation or adduction was observed after transecting the lower subscapular nerve. CONCLUSIONS: The lower subscapular nerve can be used as a safe and effective neurotization tool for upper brachial plexus injury, having a success rate of 69.2% for axillary nerve repair. Our technique presents a suitable alternative for patients with concomitant radial nerve injury.
- MeSH
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Scapula surgery MeSH
- Nerve Transfer adverse effects methods MeSH
- Brachial Plexus Neuropathies surgery MeSH
- Paralysis surgery MeSH
- Brachial Plexus injuries surgery MeSH
- Postoperative Complications epidemiology MeSH
- Child, Preschool MeSH
- Shoulder pathology surgery MeSH
- Nerve Regeneration MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Child, Preschool MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Research Support, Non-U.S. Gov't MeSH
Chirurgická léčba poraněného brachiálního plexu (BP) zaznamenala v posledních desetiletích výrazný pokrok a rozvoj. V současné době umožňují techniky primární rekonstrukce BP (štěpování a neurotizace) i sekundární korekční zákroky (šlachové a svalové transfery, volné svalové přenosy, artrodézy a další zákroky na kloubech a kostech) výrazné zlepšení funkce postižené horní končetiny u tohoto invalidizujícího poranění. Podmínkou pro dosažení nejlepších možných výsledků léčby je komplexní a individuální přístup k pacientovi v rámci multidisciplinárního týmu odborníků věnujících se této problematice. Zásadní význam pro výsledný stav má i adekvátní a dlouhodobě vedená pooperační péče. Přestože se postižená horní končetina u nejtěžších typů poranění BP nikdy nevrátí do plně funkčního stavu, představuje každé zlepšení kondice paretické končetiny pro postiženého zásadní posun v kvalitě života.
Surgical management of brachial plexus (BP) injuries has achieved significant evolution throughout the last decades. Currently, primary techniques of BP reconstruction (grafting, neurotization) along with secondary correction procedures (tendon transfers, free functional muscle transfers, arthrodesis, other bone/joint procedures), allow a high degree of functional recovery of the disabled limbs. The main requirement for achieving ideal therapeutic results, is a complex approach by a team of experienced specialists, tailored to each individual patient accordingly. Adequately planned long-term postoperative care is a crucial component of the therapeutic process. Although patients with severe cases of BP injury have little chance regaining full physical function, even minor functional improvement of the paretic limb results in major improvement in overall quality of life.
