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Spinal cord implantation of avulsed ventral roots: human application
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There were 33 girls and 41 boys, 42 right and 32 left sides. The average birth weight was 4398 g with only one case of breech presentation. The average age of operation was 7.73 months with an extreme of 110 months old. 54 patients were operated before 5 months. Depending on the number of roots ruptured, the strategy of repair sometimes included extra plexual neurotization with intercostals, spinal accessory or contralateral pectorals major nerves. In all cases the hand was a priority. Recovery is long, over two years and 100 secondary operations were necessary. The results have been assessed at 2,3,4, and 6 years after the operation. Every year, these results have been examined separately for the hand, elbow and shoulder. The overall hand results show, that after 2 years 46% of the reviewed patients were classified in stage 2 and 30% in stage 3. At 5 years after surgery only 35% were in stage 2 but 50% in stage 3. After 6 years even 50% were in stage 3 and only 20% in stage 2. Also stage 4 increased from 12% at 3 years to 25% at 6 years. Overviewing the elbow results, we found that 2 years after surgery 53% of patients were in stage 2, while after 4 years 71% were classed into stage 3. Concerning the shoulder, the final results show the majority of patients in stage 2 (45.1%) after 2 years, in stage 3 (40%) after 3 years, in stage 4 (30%) after 5 years and in stage 5 (38.5%) after 6 years. The results confirm the choice of the strategy of priority in hand reconstruction. Even with that choice, acceptable results can be expected in shoulder and elbow function,
Reconstruction of complete paralysis of upper extremity J. G o u s h e h
Shahid Beheshti University oJ"Medical Sciences, Tehran, Iran In cases for which the complete lesions of the brachial plexus are not directly reparable, different procedures have been used for the reactivation of some of the movements of the upper extremity. However, these procedures are incapable of the reactivation of digital flexion or extension in adult cases. With the use of our proposed procedure digital flexion and extension are produced, in addition to creating all other reactivations possible by existing procedures. The procedure is relatively simple: the biceps muscle is recovered using neurotization of the musculocutaneous nerve by the spinal accessory nerve (Xlth). Usually the strength of this muscle reaches M3 to M4 level after 1 year. At this stage the distal end of the biceps muscle is cut and connected to the profundus digitorum flexor tendons via a graft of tensor fascia lata, which is passed through a tunnel under the skin of the forearm. Flexion movements and physiotherapy start 1 month after the operation. For digital extension, the neurovascular gracilis transfer is used and its nerve is directly sutured to a transpectoral nerve graft. This transferred muscle usually generates M2 to M3 level force which is sufficient for the antagonist fimction to the flexor muscle. Up to now we have performed this procedure for 17 cases (14 males and 3 females), who have an average age of 23 years. In our opinion the results of this procedure have been good. The biceps muscle can reanimate the flexion of fingers with approximately the normal range. This function along with the reanimation of the elbow flexion, is very satisfactory for these
THE J O U R N A L OF H A N D SURGERY VOL. 21B S U P P L E M E N T 1
patients who have had complete paralysis of the upper extremity. The patients can usually handle 2 kg objects easily. Moreover, with the contraction and tonus of the biceps muscle, some degree of stability of the shoulder joint is established, hence we did not need to even consider arthrodesis of this joint.
The results of untreated nerve injuries in the forearm W. Manikowski, L. Romanowski, A. Czaja
Hand Surgery Department, University of Medical Sciences, Poznan, Poland It is not questioned that an injured nerve should be reconstructed. The question is what result can be achieved in inverterate nerve lesions. We present an analysis of patients with nerve reconstructions performed between 1 and 2 years from injury.
Materials and methods We analysed a group of 42 patients with nerve injuries which for various reasons had the initial reconstruction performed. 12 to 24 months from injury: 85% were male, the median nerve was injured in 17 patients, the ulnar nerve in I1 and both nerves were injured in 14. Injuries to sensory nerves only were excluded. We examined deep and superficial pain sensibility, touch, two-point discrimination, stereognosis, motor recovery and cold intolerance. We also asked the patients their opinion and work status.
Results The assessment used the scale SO to $4 and M0 to M. We also used our own Strzyzewski classifcation, which is probably more useful in assessing the result of late reconstructions. The results are not satisfactory. Motor recovery was M0 to M2 in 90% of patients. Sensory recovery was SO to $2+ in 70% and $3 to $4 in the remaining 30%. Cold intolerance was found in in 90% of patients. The patients' own opinions were surprisingly high.
Conclusions After reconstructing inverterate nerve lesions a moderate result may be all that can be expected, yet reconstruction is necessary.
Spinal cord implantation of avulsed ventral roots: human application T. Carlstedt, P. Grane, R. Hallin*, G. N o r e n
Department of Orthopaedics, Neuroradiology & Neurosurgery, Karolinska Hospital & *Department of Neurophysiology, Huddinge Hospital, Stockholm, Sweden Spinal cord implantation of avulsed ventral roots promotes restoration of muscle activity. The functional integration of the regenerated motoneurons in spinal cord circuits and their destination was unequivocally demonstrated by intracellular physiology and staining techniques. Initial regrowth of motor axons through the spinal cord occurred in a modified CNS environment that contained tissue components like laminin and the low affinity neurotrophin receptoL specific for regeneration within the PNS. In primates, intraspinal replantation of avulsed ventral roots significantly promoted motor recovery in the muscles supplied by the lesioned spinal cord segments. This surgical strategy has now been applied clinically in humans with brachial plexus injury.
SESSION 2
In a case of total brachial plexus lesion the C6, C7, C8 and Thl roots had been avulsed from the spinal cord. The C6 rootlets, which were found in the subdural space, were directly implanted into the spinal cord. The C7 spinal nerve was coapted to its spinal cord segment by means of two 7-8 cm long grafts of sural nerve that were implanted into the spinal cord through small slits in the pia mater. Electromyography (EMG) 4 months after surgery demonstrated only denervation activity. The first voluntary E M G activity could been seen 10 months after surgery in proximal a r m muscles. The first clinical activity was noted in the deltoid, biceps and triceps muscles
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1 year after surgery. Elbow flexion eventually increased. After 3 years the force in m. biceps was M3 (according to the MRC scale 0-5). Weak voluntary activity was also noted in the deltoid, triceps and brachioradial muscles. Signs of cocontraction occurred. Functional return from repair of spinal nerve roots would have a considerable clinical potential for instance in the management of bv~tchial plexus injuries. The present clinical application of a surgical strategy for ventral root avulsion, demonstrates that motor recovery leading to gross movements is possible.
There were 33 girls and 41 boys, 42 right and 32 left sides. The average birth weight was 4398 g with only one case of breech presentation. The average age of operation was 7.73 months with an extreme of 110 months old. 54 patients were operated before 5 months. Depending on the number of roots ruptured, the strategy of repair sometimes included extra plexual neurotization with intercostals, spinal accessory or contralateral pectorals major nerves. In all cases the hand was a priority. Recovery is long, over two years and 100 secondary operations were necessary. The results have been assessed at 2,3,4, and 6 years after the operation. Every year, these results have been examined separately for the hand, elbow and shoulder. The overall hand results show, that after 2 years 46% of the reviewed patients were classified in stage 2 and 30% in stage 3. At 5 years after surgery only 35% were in stage 2 but 50% in stage 3. After 6 years even 50% were in stage 3 and only 20% in stage 2. Also stage 4 increased from 12% at 3 years to 25% at 6 years. Overviewing the elbow results, we found that 2 years after surgery 53% of patients were in stage 2, while after 4 years 71% were classed into stage 3. Concerning the shoulder, the final results show the majority of patients in stage 2 (45.1%) after 2 years, in stage 3 (40%) after 3 years, in stage 4 (30%) after 5 years and in stage 5 (38.5%) after 6 years. The results confirm the choice of the strategy of priority in hand reconstruction. Even with that choice, acceptable results can be expected in shoulder and elbow function,
Reconstruction of complete paralysis of upper extremity J. G o u s h e h
Shahid Beheshti University oJ"Medical Sciences, Tehran, Iran In cases for which the complete lesions of the brachial plexus are not directly reparable, different procedures have been used for the reactivation of some of the movements of the upper extremity. However, these procedures are incapable of the reactivation of digital flexion or extension in adult cases. With the use of our proposed procedure digital flexion and extension are produced, in addition to creating all other reactivations possible by existing procedures. The procedure is relatively simple: the biceps muscle is recovered using neurotization of the musculocutaneous nerve by the spinal accessory nerve (Xlth). Usually the strength of this muscle reaches M3 to M4 level after 1 year. At this stage the distal end of the biceps muscle is cut and connected to the profundus digitorum flexor tendons via a graft of tensor fascia lata, which is passed through a tunnel under the skin of the forearm. Flexion movements and physiotherapy start 1 month after the operation. For digital extension, the neurovascular gracilis transfer is used and its nerve is directly sutured to a transpectoral nerve graft. This transferred muscle usually generates M2 to M3 level force which is sufficient for the antagonist fimction to the flexor muscle. Up to now we have performed this procedure for 17 cases (14 males and 3 females), who have an average age of 23 years. In our opinion the results of this procedure have been good. The biceps muscle can reanimate the flexion of fingers with approximately the normal range. This function along with the reanimation of the elbow flexion, is very satisfactory for these
THE J O U R N A L OF H A N D SURGERY VOL. 21B S U P P L E M E N T 1
patients who have had complete paralysis of the upper extremity. The patients can usually handle 2 kg objects easily. Moreover, with the contraction and tonus of the biceps muscle, some degree of stability of the shoulder joint is established, hence we did not need to even consider arthrodesis of this joint.
The results of untreated nerve injuries in the forearm W. Manikowski, L. Romanowski, A. Czaja
Hand Surgery Department, University of Medical Sciences, Poznan, Poland It is not questioned that an injured nerve should be reconstructed. The question is what result can be achieved in inverterate nerve lesions. We present an analysis of patients with nerve reconstructions performed between 1 and 2 years from injury.
Materials and methods We analysed a group of 42 patients with nerve injuries which for various reasons had the initial reconstruction performed. 12 to 24 months from injury: 85% were male, the median nerve was injured in 17 patients, the ulnar nerve in I1 and both nerves were injured in 14. Injuries to sensory nerves only were excluded. We examined deep and superficial pain sensibility, touch, two-point discrimination, stereognosis, motor recovery and cold intolerance. We also asked the patients their opinion and work status.
Results The assessment used the scale SO to $4 and M0 to M. We also used our own Strzyzewski classifcation, which is probably more useful in assessing the result of late reconstructions. The results are not satisfactory. Motor recovery was M0 to M2 in 90% of patients. Sensory recovery was SO to $2+ in 70% and $3 to $4 in the remaining 30%. Cold intolerance was found in in 90% of patients. The patients' own opinions were surprisingly high.
Conclusions After reconstructing inverterate nerve lesions a moderate result may be all that can be expected, yet reconstruction is necessary.
Spinal cord implantation of avulsed ventral roots: human application T. Carlstedt, P. Grane, R. Hallin*, G. N o r e n
Department of Orthopaedics, Neuroradiology & Neurosurgery, Karolinska Hospital & *Department of Neurophysiology, Huddinge Hospital, Stockholm, Sweden Spinal cord implantation of avulsed ventral roots promotes restoration of muscle activity. The functional integration of the regenerated motoneurons in spinal cord circuits and their destination was unequivocally demonstrated by intracellular physiology and staining techniques. Initial regrowth of motor axons through the spinal cord occurred in a modified CNS environment that contained tissue components like laminin and the low affinity neurotrophin receptoL specific for regeneration within the PNS. In primates, intraspinal replantation of avulsed ventral roots significantly promoted motor recovery in the muscles supplied by the lesioned spinal cord segments. This surgical strategy has now been applied clinically in humans with brachial plexus injury.
SESSION 2
In a case of total brachial plexus lesion the C6, C7, C8 and Thl roots had been avulsed from the spinal cord. The C6 rootlets, which were found in the subdural space, were directly implanted into the spinal cord. The C7 spinal nerve was coapted to its spinal cord segment by means of two 7-8 cm long grafts of sural nerve that were implanted into the spinal cord through small slits in the pia mater. Electromyography (EMG) 4 months after surgery demonstrated only denervation activity. The first voluntary E M G activity could been seen 10 months after surgery in proximal a r m muscles. The first clinical activity was noted in the deltoid, biceps and triceps muscles
7
1 year after surgery. Elbow flexion eventually increased. After 3 years the force in m. biceps was M3 (according to the MRC scale 0-5). Weak voluntary activity was also noted in the deltoid, triceps and brachioradial muscles. Signs of cocontraction occurred. Functional return from repair of spinal nerve roots would have a considerable clinical potential for instance in the management of bv~tchial plexus injuries. The present clinical application of a surgical strategy for ventral root avulsion, demonstrates that motor recovery leading to gross movements is possible.