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Scott H. Kozin - One of the best experts on this subject based on the ideXlab platform.
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median and or ulnar Nerve Fascicle transfer for the restoration of elbow flexion in upper neonatal brachial plexus palsy
Jbjs Essential Surgical Techniques, 2014Co-Authors: Kevin J Little, Dan A Zlotolow, Francisco Soldado, Roger Cornwall, Scott H. KozinAbstract:[Introduction][1] Transfer of a Fascicle of the ulnar and/or median Nerve to the musculocutaneous Nerve in order to reinnervate the biceps and/or brachialis muscles has a high success rate and a low rate of complications in infants with upper (C5-C6) or extended upper (C5-C7) neonatal brachial plexus palsy. [Step 1: Make the Incision][2] Make a longitudinal incision along the midline of the middle third of the medial brachium. ![Figure][3] [Step 2: Mobilize the Musculocutaneous Nerve][4] The musculocutaneous Nerve is typically found on the undersurface of the biceps muscle. ![Figure][3] [Step 3: Mobilize the Median Nerve][5] The median Nerve runs along the neurovascular sheath medial to the brachial artery. [Step 4: Mobilize the Ulnar Nerve][6] The ulnar Nerve lies posterior to the intermuscular septum. ![Figure][3] [Step 5: Transfer the Donor Nerve to the Recipient Nerve][7] Cut the donor Fascicles distally and the recipient Fascicles proximally to facilitate transfer. ![Figure][3] ![Figure][3] [Step 6: Close the Wound][8] Irrigate the wound, and close it in layers. [Step 7: Postoperative Protocol][9] Remove the bandages two weeks postoperatively, and encourage passive range-of-motion exercises. [Results][10] In our series, thirty-one patients underwent single or combined Nerve Fascicle transfer; twenty-seven (87%) obtained functional elbow flexion recovery (Active Movement Scale [AMS] score ≥ 6) while twenty-four (77%) obtained full elbow flexion recovery (AMS score = 7). [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] [Introduction][1] Transfer of a Fascicle of the ulnar and/or median Nerve to the musculocutaneous Nerve in order to reinnervate the biceps and/or brachialis muscles has a high success rate and a low rate of complications in infants with upper (C5-C6) or extended upper (C5-C7) neonatal brachial plexus palsy. [Step 1: Make the Incision][2] Make a longitudinal incision along the midline of the middle third of the medial brachium. ![Figure][3] [Step 2: Mobilize the Musculocutaneous Nerve][4] The musculocutaneous Nerve is typically found on the undersurface of the biceps muscle. ![Figure][3] [Step 3: Mobilize the Median Nerve][5] The median Nerve runs along the neurovascular sheath medial to the brachial artery. [Step 4: Mobilize the Ulnar Nerve][6] The ulnar Nerve lies posterior to the intermuscular septum. ![Figure][3] [Step 5: Transfer the Donor Nerve to the Recipient Nerve][7] Cut the donor Fascicles distally and the recipient Fascicles proximally to facilitate transfer. ![Figure][3] ![Figure][3] [Step 6: Close the Wound][8] Irrigate the wound, and close it in layers. [Step 7: Postoperative Protocol][9] Remove the bandages two weeks postoperatively, and encourage passive range-of-motion exercises. [Results][10] In our series, thirty-one patients underwent single or combined Nerve Fascicle transfer; twenty-seven (87%) obtained functional elbow flexion recovery (Active Movement Scale [AMS] score ≥ 6) while twenty-four (77%) obtained full elbow flexion recovery (AMS score = 7). [Indications][11] [Contraindications][12] [Pitfalls & Challenges][13] [1]: #sec-10 [2]: #sec-11 [3]: pending:yes [4]: #sec-12 [5]: #sec-13 [6]: #sec-14 [7]: #sec-15 [8]: #sec-16 [9]: #sec-17 [10]: #sec-18 [11]: #sec-20 [12]: #sec-21 [13]: #sec-22
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early functional recovery of elbow flexion and supination following median and or ulnar Nerve Fascicle transfer in upper neonatal brachial plexus palsy
Journal of Bone and Joint Surgery American Volume, 2014Co-Authors: Kevin J Little, Dan A Zlotolow, Francisco Soldado, Roger Cornwall, Scott H. KozinAbstract:Background: Nerve transfers using ulnar and/or median Nerve Fascicles to restore elbow flexion have been widely used following traumatic brachial plexus injury, but their utility following neonatal brachial plexus palsy remains unclear. The present multicenter study tested the hypothesis that these transfers can restore elbow flexion and supination in infants with neonatal brachial plexus palsy. Methods: We retrospectively reviewed the cases of thirty-one patients at three institutions who had undergone ulnar and/or median Nerve Fascicle transfer to the biceps and/or brachialis branches of the musculocutaneous Nerve after neonatal brachial plexus palsy. The primary outcome measures were postoperative elbow flexion and supination as measured with the Active Movement Scale (AMS). Patients were followed for at least eighteen months postoperatively unless they obtained full elbow flexion or supination (AMS = 7) prior to eighteen months of follow-up. Results: Twenty-seven (87%) of the thirty-one patients obtained functional elbow flexion (AMS ≥ 6), and twenty-four (77%) obtained full recovery of elbow flexion against gravity (AMS = 7). Of the twenty-four patients for whom recovery of supination was recorded, five (21%) obtained functional recovery. Combined ulnar and median Nerve Fascicle transfers were performed in five patients and resulted in full recovery of elbow flexion against gravity and supination of AMS ≥ 5 for all five. Single-Fascicle transfer was performed in twenty-six patients and resulted in functional flexion in 85% (twenty-two of twenty-six) and functional supination in 15% (three of twenty). Patients with Nerve root avulsion were treated at a younger age (p < 0.01), had poorer preoperative elbow flexion (p < 0.01), and recovered greater supination (p < 0.01) compared with patients with dissociative recovery. Younger patients (p < 0.01) and patients with C5-C6 avulsion (p < 0.02) recovered the greatest supination. One patient sustained a transient anterior interosseous Nerve palsy after median Nerve Fascicle transfer. Conclusions: Ulnar and/or median Nerve Fascicle transfers were able to effectively restore functional elbow flexion in patients with Nerve root avulsion, dissociative recovery, or late presentation following neonatal brachial plexus palsy. Recovery of supination was less, with greater success noted in younger patients with Nerve root avulsion. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. Peer Review This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
Lynda J S Yang - One of the best experts on this subject based on the ideXlab platform.
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timing of Nerve transfer for elbow flexion in neonatal brachial plexus palsy
Neurology Psychiatry and Brain Research, 2018Co-Authors: Brandon W Smith, Kate Chang, Lynda J S YangAbstract:Abstract Background Neonatal brachial plexus palsy (NBPP) occurs in 1–4/1000 live births, and those with palsies of the upper trunk can suffer permanent loss of elbow flexion. One option for restoring elbow flexion comprises Nerve transfer from an ulnar Nerve Fascicle to the musculocutaneous Nerve branch to biceps, also known as the Oberlin procedure. Although outcomes are encouraging, the timing of surgical intervention from the time of injury continues to be controversial. Methods We performed a retrospective review of infants with NBPP who underwent Oberlin transfer procedure. Outcome measures included active range of motion and muscle power (MRC grade) at serial examinations up to 12 months. Results We demonstrate a positive trend in outcomes of elbow flexion and supination in patients intervened on earlier rather than later. Conclusions The optimal timing in the use of Oberlin transfer in the NBPP population is not well defined. Our study is the first to focus on ulnar to musculocutaneous Nerve transfer timing in NBPP, and we demonstrate a positive trend in functional outcomes with earlier surgery.
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effect of Fascicle composition on ulnar to musculocutaneous Nerve transfer oberlin transfer in neonatal brachial plexus palsy
Journal of Neurosurgery, 2018Co-Authors: Brandon W Smith, Nicholas J Chulski, Ann A Little, Kate W C Chang, Lynda J S YangAbstract:OBJECTIVE Neonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%-40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar Nerve Fascicle that innervates the flexor carpi ulnaris as the donor Nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar Nerve Fascicle choice with functional elbow flexion outcome in NBPP. METHODS The authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous Nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar Nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific Fascicle transfer (1-2 muscles for either wrist flexion or hand intrinsics) and nonspecific Fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups. RESULTS The patients' average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor Fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific Fascicle transfer group versus 36° in the nonspecific Fascicle transfer group, with no statistically significant difference (p = 0.93). CONCLUSIONS Both specific and nonspecific Fascicle transfers led to functional recovery, but that the composition of the donor Fascicle had no impact on early outcomes. In young infants, ulnar Nerve fascicular dissection places the ulnar Nerve at risk for iatrogenic damage. The data from this study suggest that the use of any motor Fascicle, specific or nonspecific, produces similar results and that the Oberlin transfer can be performed with less intrafascicular dissection, less time of surgical exposure, and less potential for donor site morbidity.
Christophe Oberlin - One of the best experts on this subject based on the ideXlab platform.
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transfer of Fascicles from the ulnar Nerve to the Nerve to the biceps in the treatment of upper brachial plexus palsy
Journal of Bone and Joint Surgery American Volume, 2004Co-Authors: Frederic Teboul, Raoul Kakkar, Nordine Ameur, Jeansyves Beaulieu, Christophe OberlinAbstract:Background: The transfer of one or more ulnar Nerve Fascicles to the Nerve to the biceps can restore elbow flexion in patients with upper brachial plexus palsy. The purposes of the present retrospective study were to evaluate the results of this procedure, to measure the delay in reinnervation of the biceps muscle, and to define the indications for a secondary Steindler flexorplasty. Methods: Thirty-two patients with an upper Nerve-root brachial plexus injury were reviewed at an average of thirty-one months after the Nerve Fascicle transfer. The average age of the patients was twenty-eight years. The average time between the injury and the operation was nine months. Patients were evaluated with regard to reinnervation of the biceps, ulnar Nerve function, elbow flexion strength, and grip strength. Results: The average time required for reinnervation of the biceps after Nerve Fascicle transfer was five months. No motor or sensory deficits related to the ulnar Nerve were noted clinically. The average grip strength at the time of the last follow-up was 25 kg (an improvement of 9 kg compared with the preoperative value). After the Nerve transfer, twenty-four patients achieved grade-3 elbow flexion strength or better according to the grading system of the Medical Research Council. A Steindler flexorplasty was performed as a secondary procedure in ten patients with persistent grade-3 flexor strength or worse. In eight of these cases, elbow flexion strength improved after Nerve transfer and flexorplasty. Overall, thirty of the thirty-two patients achieved a good result (grade-4 strength) or a fair result (grade-3 strength). Conclusions: We recommend this procedure for brachial plexus injuries involving the C5-C6 or C5-C6-C7 Nerve roots. This procedure spares the C5 Nerve root and other Nerves for grafting or transfer elsewhere. A secondary Steindler flexorplasty is indicated for patients who have persistent grade-3 elbow flexion strength or worse for at least twelve months after Nerve Fascicle transfer. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
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ulnar Nerve Fascicle transfer onto to the biceps muscle Nerve in c5 c6 or c5 c6 c7 avulsions of the brachial plexus eighteen cases
Annales de chirurgie de la main et du membre superieur : organe officiel des societes de chirurgie de la main = Annals of hand and upper limb surgery, 1997Co-Authors: S Loy, A Bhatia, H Asfazadourian, Christophe OberlinAbstract:The authors report 18 cases of transfer of several ulnar Nerve Fascicles onto the biceps muscle Nerve, performed between 1990 and 1997. The patients were between the ages of 17 and 41 years, and presented C5-C6 paralysis in 8 cases and C5-C6-C7 paralysis in 10 cases. The operation was tempted between 4 months and 6 years (m = 17 months) after the initial accident. In the 8 cases of C5-C6 paralysis reviewed, 7 patients recovered elbow flexion and only one required an additional Steindler transfer. In the 9 cases of C5-C6-C7 paralysis reviewed, 4 patients recovered elbow flexion after Nerve surgery alone, while 4 patients only obtained elbow flexion after a complementary Steindler transfer. Two of these 4 patients were operated very late (27 and 75 months). Finally, a single 40-year-old patient, operated 28 months after the accident, was considered to be a complete failure. Overall, ulnar biceps Nerve transfer appears to be indicated in C5-C6 avulsion, during the months following the initial accident. Flexion against gravity is then regularly obtained in less than 6 months, without any objective or subjective sequelae of the hand.
Susan E Mackinnon - One of the best experts on this subject based on the ideXlab platform.
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Nerve transfer to the triceps after brachial plexus injury: report of four cases.
The Journal of hand surgery, 2011Co-Authors: Mitchell A. Pet, Wilson Z. Ray, Andrew Yee, Susan E MackinnonAbstract:These case reports review the clinical outcomes of 4 patients who underwent Nerve transfer to a triceps motor branch of the radial Nerve. Mean follow-up was 26 ± 15 months. Two patients had a transfer using an ulnar Nerve Fascicle to the flexor carpi ulnaris muscle, yielding a motor recovery of grade M5 elbow extension strength in one case and M4+ in the other. In 1 patient, a thoracodorsal Nerve branch was used as the donor; this patient recovered M4 strength. One patient had a transfer using a radial Nerve Fascicle to the extensor carpi radialis longus muscle and recovered M5 strength. These outcomes indicate that expendable Fascicles of the ulnar, thoracodorsal, and radial Nerves are viable donors in the surgical reconstruction of elbow extension.
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Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries
Journal of Neurosurgery, 2003Co-Authors: Thomas H Tung, Christine B Novak, Susan E MackinnonAbstract:Object. In this study the authors evaluated the outcome in patients with brachial plexus injuries who underwent Nerve transfers to the biceps and the brachialis branches of the musculocutaneous Nerve. Methods. The charts of eight patients who underwent an ulnar Nerve Fascicle transfer to the biceps branch of the musculocutaneous Nerve and a separate transfer to the brachialis branch were retrospectively reviewed. Outcome was assessed using the Medical Research Council (MRC) grade to classify elbow flexion strength in conjunction with electromyography (EMG). The mean patient age was 26.4 years (range 16–45 years) and the mean time from injury to surgery was 3.8 months (range 2.5–7.5 months). Recovery of elbow flexion was MRC Grade 4 in five patients, and Grade 4+ in three. Reinnervation of both the biceps and brachialis muscles was confirmed on EMG studies. Ulnar Nerve function was not downgraded in any patient. Conclusions. The use of Nerve transfers to reinnervate the biceps and brachialis muscle provide...
Thomas Schelle - One of the best experts on this subject based on the ideXlab platform.
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ultrasonography in neuralgic amyotrophy sensitivity spectrum of findings and clinical correlations
Muscle & Nerve, 2017Co-Authors: Zsuzsanna Aranyi, Anita Csillik, Katalin Devay, Maja Rosero, Peter Barsi, Josef Böhm, Thomas SchelleAbstract:Introduction: The aim of this study was to assess the value of ultrasonography in neuralgic amyotrophy. Methods: Fifty-three patients with 70 affected Nerves were examined with high resolution ultrasound. Results: The most commonly affected Nerve was the anterior interosseous (23%). Ultrasonographic abnormalities in the affected Nerves, rather than in the brachial plexus, were observed with an overall sensitivity of 74%. Findings included the swelling of the Nerve/Fascicle with or without incomplete/complete constriction and rotational phenomena (Nerve torsion and fascicular entwinement). A significant difference was found among the categories of ultrasonographic findings with respect to clinical outcome (p=0.01). In Nerves with complete constriction and rotational phenomena, reinnervation was absent or negligible, indicating surgery was warranted. Discussion: Ultrasonography may be used as a diagnostic aid in neuralgic amyotrophy, which was hitherto a clinical and electrophysiological diagnosis, and may also help in identifying potential surgical candidates. This article is protected by copyright. All rights reserved.
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ultrasonographic identification of Nerve pathology in neuralgic amyotrophy enlargement constriction fascicular entwinement and torsion
Muscle & Nerve, 2015Co-Authors: Zsuzsanna Aranyi, Anita Csillik, Katalin Devay, Maja Rosero, Peter Barsi, Josef Böhm, Thomas SchelleAbstract:Introduction The aim of this study was to characterize the ultrasonographic findings on Nerves in neuralgic amyotrophy. Methods Fourteen patients with neuralgic amyotrophy were examined using high-resolution ultrasound. Results Four types of abnormalities were found: (1) focal or diffuse Nerve/Fascicle enlargement (57%); (2) incomplete Nerve constriction (36%); (3) complete Nerve constriction with torsion (50%; hourglass-like appearance); and (4) fascicular entwinement (28%). Torsions were confirmed intraoperatively and were seen on the radial Nerve in 85% of patients. A significant correlation was found between no spontaneous recovery of Nerve function and constriction/torsion/fascicular entwinement (P = 0.007). Conclusion Ultrasonographic Nerve pathology in neuralgic amyotrophy varies in order of severity from Nerve enlargement to constriction to Nerve torsion, with treatment ranging from conservative to surgical. We postulate that the constriction caused by inflammation is the precursor of torsion and that development of Nerve torsion is facilitated by the rotational movements of limbs. Muscle Nerve 52: 503–511, 2015