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2012 CRN - Acute Nerve Injury and Repair - Part 2

Comprehensive Review of Neurosurgery; Part 2 - Nerve Transfers in the Hand; 5/2/2012
by Andrew Yee on 30 September 2013

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Transcript of 2012 CRN - Acute Nerve Injury and Repair - Part 2

Nerve Transfers
Peripherial Nerve Surgery Education
nervesurgery.wustl.edu

Surgical Video Library
https://vimeo.com/user6062882

Prezi Presentation
http://prezi.com/user/yeeandrew/
Credits
Andrew Yee, BS
Classification of Nerve Injuries
Supercharge
Nerve Transfers
(+)
(+)
Nerve Transfers
I
II
IV
III
V
VI
Recipient Nerve
Distal
Distance Time
Time Muscle
Muscle Function
Results of Nerve Grafting
Results of Nerve Transfers
Medial Pectoral to Musculocutaneous
Nerve Transfer
Thoracodorsal to Axillary
Nerve Transfer
Nerve Anatomy
Donor
Recipient
End-to-end
Donor
Recipient
Supercharge
End-to-side
Muscle
Neuron Cell Body (
Gateway Arch
)
Anchorage, AK
St. Louis, MO
Muscle
Neuron Cell Body (
Gateway Arch
)
Anchorage, AK
St. Louis, MO
Fairbanks, AK
Adjacent Neuron Fibers
Nerve Injury and Recovery
Nerve Transfers
II Degree
III Degree
donor nerve
near target muscle
expendable donor nerve
donor nerve with "pure" motor fibers
donor nerve with large number of motor axons
donor muscle is synergistic to target muscle
Indications
need to direct a large number of motor axons quickly to denervated muscle

Nerve Transfer provides:
source of nerve in close proximity to the denervated muscle
faster and superior muscle reinnervation
Median to Radial Nerve Transfer
Brachialis to Anterior Interosseous Nerve Transfer
Brachialis to AIN / PT Nerve Transfer
Post-operative Results
Pronation and AIN Function - 2 Years
Pronation and AIN Function - 4 Years
Donor
Recipient
Recipient
Recipient
Recipient
Donor
Recipient
Recipient
Donor
FCR
Wrist Flexion
Finger Extension
PIN
FDS
Finger Flexion
Wrist Extension
ECRB
Nerve Transfers
I
II
Radial Nerve Injury
Wrist Drop
Median to Radial Nerve Transfers
Humeral Fractures
Old Anatomy
Median and Radial Nerve Anatomy
Nerve Transfers
Surgical Procedure
Orientation
Lateral Antebrachial Cutaneos Nerve
Radial Vessels Landmark
Step-lengthening Pronator Teres Tendon
Release of Deep Head of Pronator Teres
Arch of Flexor Digitorum Superficialis
Median Nerve Anatomy
Exposure of Radial Nerve
Radial Nerve Anatomy
Median and Radial Nerve
Removal of Supinator Branch
Donr Distal, Recipient Proximal
Median to Radial Nerve Transfers
Median to Radial Nerve Transfers
Outcomes
Outcomes
9 Month Post-operative
1 Year Post-operative
Median

(FCR / FDS)
to
Radial (PIN / ECRB)
Nerve Transfer
Median

(FCR / FDS)
to
Radial (PIN / ECRB)
Nerve Transfer
4 Year Post-operative
Current Anatomy
Median to Radial Nerve Transfers
Median and Radial Nerve Anatomy
Incision
Restoration of Hand Function
Restoration of Hand Sensation
Radial Nerve
Median to radial transfer
FDS
to
ECRB
transfer
FCR
to
PIN
transfer
Supinator
to
PIN
transfer

Pronator Teres Nerve
ECRB
to
pronator teres
transfer
FDS
to
pronator teres
transfer
FCR
to pronator teres transfer
FCU
to
pronator teres
transfer

Anterior Interosseous Nerve of Median Nerve
Brachialis
to
anterior interosseous
transfer
ECRB
to
anterior interosseous
transfer
Supinator
to
anterior interosseous
transfer
FDS
to
anterior interosseous
transfer

Flexor Pollicis Longus of Median Nerve
FDS
to
FPL
transfer

Recurrent Thenar Branch of Median Nerve
Anterior interosseous (PQ)
to
recurrent thenar
transfer with graft

Deep Motor Branch of Ulnar Nerve
Anterior interosseous (PQ)
to
ulnar motor
transfer
EDQ / ECU
to
ulnar motor
transfer with graft

ECRB to Anterior Interosseous Nerve Transfer
Supinator to Anterior Interosseous Nerve Transfer
FDS to Anterior Interosseous Nerve Transfer
FDS to FPL Nerve Transfer
Anterior Interosseous (PQ) to Ulnar Motor Nerve Transfer
LABC to Radial Sensory Nerve Transfer
3rd to 1st Webspace Nerve Transfer
DCU to Critical Median Sensory Nerve Transfer
3rd Webspace to Ulnar Sensory Nerve Transfer
Anterior Interosseous (PQ) to Recurrent Thenar Nerve Transfer with Graft
ECRB to Pronator Teres Nerve Transfer
FDS to Pronator Teres Nerve Transfer
FCU to Pronator Teres Nerve Transfer
3rd Webspace (Donor)
and
1st Webspace (Recipient)
Critical ETE Nerve Transfer
Non-critical ETS Nerve Transfer
3rd Webspace
to
1st Webspace
Ulnar Sensory
to
Distal 3rd Webspace
I.
II.
Dorsal Cutaneous Ulnar (Donor)
and
1st and 2nd Webspace (Recipient)
Critical ETE Nerve Transfer
I.
Ulnar Sensory
to
1st and 2nd Webspace
Ulnar Sensory
to
3rd Webspace
II.
Non-critical ETS Nerve Transfer
Ulnar Sensory
to
Distal Dorsal Cutaneous Ulnar
3rd Webspace (Donor)
II.
Median Sensory
to
Distal 3rd Webspace
Non-critical ETS Nerve Transfer
3rd Webspace (Donor)
and
Ulnar Sensory (Recipient)
Critical ETE Nerve Transfer
I.
3rd Webspace
to
Ulnar Sensory
II.
3rd Webspace
to
Dorsal Cutaneous Ulnar
Non-critical ETS Nerve Transfer
Sensory Transfers Summary
MEDIAN
ULNAR
RADIAL
Donor
Anterior Interosseous Nerve (PQ)
Recipient
Ulnar Motor Component
(N) ulnar motor component
(N) ulnar sensory component
(N) dorsal cutaneous branch of ulnar
Recipient
(N) dorsal cutaneous branch of ulnar
(N) anterior interosseous (PQ)
Donor
Nerve Transfer
(N) ulnar motor component
(N) ulnar sensory component
Recipient
(N) anterior interosseous (PQ)
Donor
(N) 3rd webspace of median
Nerve Transfer
(N) ulnar motor component
(N) ulnar sensory component
Recipient
Post-operative Results
Recipient Proximal
Adjunct Procedures
FDP
Tenodesis
Guyon's Canal Release with
Deep Motor Branch
early recovery of ulnar extrinsic function
prevent possible compression inhibiting regeneration
(N) pronator teres
Recipient
FCR to Pronator Teres Nerve Transfer
(N) flexor digitorum superficialis
Donor
(N) pronator teres
Recipient
(N) pronator teres
Recipient
(N) flexor digitorum superficialis
Donor
(N) flexor digitorum superficialis
Donor
(N) pronator teres
Recipient
(N) extensor carpi radialis brevis
Donor
(N) anterior interosseous
Recipient
(N) anterior interosseous
Recipient
(N) anterior interosseous
Recipient
(N) extensor carpi radialis brevis
Donor
(N) extensor carpi radialis brevis
Donor
Complete Median Nerve Injury
AIN Palsy
(N) flexor digitorum superficialis
Donor
(N) anterior interosseous
Recipient
(N) flexor digitorum superficialis
Donor
(N) anterior interosseous
Recipient
(N) flexor digitorum superficialis
Donor
(N) anterior interosseous
Recipient
(N) flexor digitorum superficialis
Donor
(N) anterior interosseous
(N) flexor pollicis longus
Recipient
(N) remaining anterior interosseous
(N) flexor digitorum superficialis
Donor
(N) flexor digitorum superficialis
Donor
(N) flexor pollicis longus
Recipient
Post-operative Results
Pre-operative Examination
C5, C6 Palsy
3rd
to
1st webspace
transfer

Median Nerve
Dorsal cutaneous branch of ulnar
to
1st webspace
transfer

Ulnar Nerve
3rd webspace
to
ulnar sensory
transfer

Radial Nerve
LABC
to
radial sensory
transfer

Sensory Nerve Transfers
End-to-end (ETE) vs End-to-side (ETS)
Early Sensory Nerve Transfers
critical sensation
non-critical sensation
preserving distal donor
sensory nerves
Restoration of 1st Webspace
4th
to
1st Webspace
(ETE) Nerve Transfer

Restoration of 2nd / 3rd Webspace
Ulnar Sensory
to
2nd / 3rd Webspace
(ETE) Nerve Transfer

Restoration of Ulnar Nerve Sensation
Median Sensory
to
Ulnar Sensory
(ETS) Nerve Transfer
Median Sensory
to
Dorsal Cutaneous Ulnar
(ETS) Nerve Transfer
ETS Neurorrhaphy
ETS Neurorrhaphy
Total Fiber Number
Perineurial Window
Larger perineurial window induces greater collateral sprouting.
Spontaneous Collateral Sprouting
Pannucci C, et al .
End-to-side nerve repair: review of the literature.
Restor Neurol Neurosci. 25:45-63, 2007.
MOTOR
SENSORY
(N) extensor carpi radialis brevis
Donor
(N) extensor carpi radialis brevis
Donor
(N) pronator teres
Recipient
Interfascicular Anatomy of Median Nerve
Interfascicular Anatomy of Median Nerve
Electrical Stimulation of Left AIN Fascicle
Donor
: Brachialis Branch
Recipient
: AIN Fascicle
2 Years Post-Injury
Left - Brachialis to AIN Nerve Transfer
Histomorphometry
Post-operative Results
Functional Recovery - 1 Year
Melt My Wings
Nerve Fibers: ~3222
Nerve Fibers: ~3512
Right - Brachialis to AIN Nerve Transfer
Melt My Wings
71 Year-old Male
Spinal Cord Injury: ~C7 Level
Restoration of AIN Function in SCI Patient
Pre-operative Examination
Left Arm Examination
Right Arm Examination
Electrical Stimulation of Right AIN Fascicle
2 Years Post-Injury
2 Years Post-Injury
SCI Brachialis to Anterior Interosseous Nerve Transfer
(N) flexor digitorum superficialis
Donor
(N) posterior interosseous
Recipient
(N) flexor carpi radialis
Donor
(N) extensor carpi radialis brevis
Recipient
radial vessels
(N) radial sensory
(M) pronator teres tendon
(N) flexor digitorum superficialis
Donor
(N) flexor carpi radialis
Donor
(N) posterior interosseous
Recipient
(N) extensor carpi radialis brevis
Recipient
(N) posterior interosseous
Recipient
(N) supinator
(N) flexor digitorum superficialis
Donor
(N) flexor carpi radialis
Donor
(N) posterior interosseous
Recipient
(N) extensor carpi radialis brevis
Recipient
(N) flexor digitorum superficialis
Donor
(N) flexor carpi radialis
Donor
(N) posterior interosseous
Recipient
(N) extensor carpi radialis brevis
Recipient
Supercharging
the Injured Nerve

I.
II.
End-to-end
Nerve Transfer
=
Supercharge
Nerve Transfer
Partial Injury Model
2nd / 3rd Degree Injury - Axonotmesis
Supercharge in
Incomplete Injury
Partial Injury - Graft
Supercharge Nerve Transfer
Functional Results
Muscle Force Analysis
Specific Force (N/cm2)
Partial Injury
Supercharge
Supercharge in Incomplete Injury
with
Donor

Transection
Transection
Functional Results
Muscle Force Analysis
Specific Force (N/cm2)
Partial Injury
Supercharge
Additional Regenerative Front
Proximal Regenerative Front
2nd / 3rd Degree Nerve Injury
(Axonotmesis)
Supercharge in Incomplete Injury
Transgenic Animal Models
Supercharge Experimental Study
Research
Clinical
Pre-operative
Post-operative
Ulnar Nerve Injury
Clawing
1st Dorsal Interosseous Wasting
Muscle
Neuron Cell Body (
Gateway Arch
)
Anchorage, AK
St. Louis, MO
Fairbanks, AK
Adjacent Neuron Fibers
Supercharge
Anterior Interosseous to Ulnar Motor Nerve Nerve Transfer
Orientation
DONOR
- Anterior Interosseous Nerve
RECIPIENT
- Ulnar Motor Fascicle
Right - 3/58
Right - 23/102
Pinch / Grip
Pinch / Grip
2 Years
Revision Ulnar Nerve Transposition
Supercharge AIN to Ulnar Motor Nerve Transfer
Guyon's Canal Release
Post-operative Outcome
Supercharge Nerve Transfer
Susan E. Mackinnon, MD

Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO
Acute Nerve Injury and Repair
I, Susan E. Mackinnon, MD, am the co-inventor of the PGA Neurotube and have received research funding from AxoGen Inc.
NIH - 5R01 NS 033406-17
Nerve Allotransplantation for Traumatic Nerve Injury
Comprehensive Review of Neurosurgery
Part II - Supercharge Nerve Transfers and Nerve Transfers in the Hand
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