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2013 PM&R - Brachial Plexus Injury and Management - Part 1 - Peripheral Nerve Surgery

2/28/13; Videos embedded with youTube.

Andrew Yee

on 1 March 2013

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Transcript of 2013 PM&R - Brachial Plexus Injury and Management - Part 1 - Peripheral Nerve Surgery

Nerve Grafting Nerve Allograft Conduit and Acellularized Allograft Nerve Transfers Nerve Repair

Nerve Grafting

Nerve Allografts


Acellularized Allografts

Nerve Transfers

End-to-side Nerve Transfers

Supercharge Nerve Transfers zone of injury
topography donor morbidity
expendability antigenicity / immunosuppression length limitation <3cm
no Schwann cells length limitation <5cm
no Schwann cells no extracellular matrix (ECM)
$ ECM (superior regeneration)
$$$ topography
motor (sensory) re-education sensory collateral sprouting
motor requires neurectomy enhances 2nd / 3rd degree injuries Strategies for
Nerve Reconstruction Nerve Axons Nerve Injury Classification of Nerve Injuries I II IV III V VI Muscle Neuron Cell Body (Gateway Arch) Anchorage, AK St. Louis, MO Nerve Injury and Recovery Distance Time
Time Muscle
Muscle Function Nerve Injury Classification of Nerve Injury A. B. C. Neuroma MABC Nerve Graft Bad Example Kawamura DH, et al. Regeneration through nerve isografts is independent of nerve geometry. J Reconstr Microsurg, 24:243-49, 2005. Avoid Nerve Graft Tension Alternatives to Sural Nerve Grafts Non-critical Proximal Injured Nerves
3rd webspace fascicle of median nerve
dorsal cutaneous branch of ulnar nerve Recovery of Donor Deficit Medial Antebrachial Cutaneous Nerve Distal End-to-side Sensory Nerve Transfer 3rd Webspace Fascicle - Donor Nerve Graft Ross D, et al. Intraneural anatomy of the median nerve provides "third web space" donor nerve graft. J Reconstr Microsurg, 8:255-32, 1992. Non-critical Proximal Nerve Graft Graft Material Distal End-to-side
Sensory Nerve Transfer Medial Antebrachial Cutaneous Nerve Graft Distal End-to-side
Sensory Nerve Transfer Median Nerve Reconstruction Graft Phenotype (Motor vs Sensory) Histomorphometry Motor Sensory Motor Cable Grafts Sensory Cable Grafts Obturator Motor Nerve Graft Deep Motor Branch of Ulnar Nerve
Reconstruction Goal: Redundancy with No Tension Good Example Microsurgical Technique Poor Repair - Too Tight Correct Repair - Alignment Scar Tissue Fascicular Pattern Zone of Injury Interneural Plexus Internal Topography Interfascicular Anatomy Courtesy of A. Van Beek, MD Ulnar Nerve Stimulation Nerve Repair Midha R, et al. Comparison of regeneration across nerve allografts with temporary or continuous cyclosporin A immunosupression. J Neurosurg, 78:90-100, 1993. Schwann Cell Migration A B C D E Immunosuppression Nerve Autograft Nerve Allograft Immunosuppression Withdrawal Intercostal Neuropathy Post-Thoracotomy Proximal Transection of Intercostel Nerves T5 Proximal Ends: T6 T7 T8 Nerve Allografts T5 T6 T7 T8 Coaptation Ends: Allograft Loops T5 Allograft T6 T7 Allograft T8 Regenerative Fronts Spine Surgical Management of Neuropathic Pain Nerve Allografts and Neuropathic Pain Neuroma Pain Proximal Transection T5 T6 T7 T8 Nerve Allografts Advantages requires systemic immunosuppression (~18 mths)
vulnerable to opportunistic infections and tumors temorary scaffold
no donor site morbidity
limitless donor nerve grafts
significant segmental injuries
FK506 promotes nerve regeneration Equals to autograft with immunosupression Disadvantages Summary Reserved for patients with otherwise irreparable extensive peripheral nerve injuries Nerve Allografts Equals to autograft with immunosupression Ulnar Nerve with Collagen Conduits (2x 6mm x 2cm) Conduit Acellularized Allograft Conduit Acellularized Allograft Autograft Acellularized Allograft Schwann Cells Conduit Conduit Matrix Schwann Cells and Matrix Gold Standard Clinical Clinical Research Research Research Clinical Conduits < Allografts < Grafts Good Results with Nerve Conduits Failed Results with Nerve Conduits 226 Digital Nerve Cases
18 Median / Ulnar Nerve Cases Median Nerve with Collagen Conduit (7mm x 2cm) Failed Case #1 Failed Case #2 Ulnar Nerve with PGA Conduit (4mm x 2cm) Proximal Distal Failed Case #3 Ulnar Nerve with Collagen Nerve Wrap (7mm x 2cm) Failed Case #4 Conduit Volume Moore AM, et al. Limitations of conduits in peripheral nerve repairs. Hand (NY). 4(2):180-6, 2009. Nerve Conduit Marketing FDA/CE Approved Nerve Conduits Meek MF, Coert JH. US food and drug adminstration/conformit Europe-approved absorbable nerve conduits for clinical repair of peripheral and cranial nerves. Ann Plast Surg. 60(1):110-6, 2008. ANA Marketing 14mm Length Study 28mm Length Study Acellularized Allografts Clinical Utility - Small Diameter Non-critical Nerves graft for non-critical sensation

extender graft
for proximal neuroma transposition
for sensory ETS transfer to provide rudimentary sensation
for sensory ETS transfer to recover donor nerve graft deficits Graft Extender ETS Sensory Transfer Extender Graft Proximal Neuroma Transposition Extender Extender Non-critical Sensation Collagen Conduit vs Acellularized Nerve Allograft (ANA) Time and Regenerative ANA Distance 6 Weeks 22 Weeks Whitlock EL, et al. Processed allografts and type 1 collagen conduits for repair of peripheral nerve gaps. Muscle and Nerve. 39:787-99, 2009. Comparison of Grafts and Conduits Moore AM, et al. Acellular nerve allografts in peripheral nerve regeneration: A comparative study. Muscle and Nerve. 44:221-34, 2011. Histomorphometery Architecture Functional - Muscle Force Architecture Sural Cable Crafting Nerve Grafting Susan E. Mackinnon, MD

Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO Brachial Plexus Injury and Management Peripherial Nerve Surgery Education

Surgical Video Library

Prezi Presentation
http://prezi.com/user/yeeandrew/ Credits Andrew Yee, BS Regeneration Distance Long Isograft Model Long Acellularized Allograft 6cm - 10weeks Physical Medicine & Rehabilitation Lecture Part I - Peripheral Nerve Surgery Localizing Level of Nerve Injury Intrinsic Ulnar Atrophy Deep Motor Branch Intrinsic Ulnar Atrophy
Ulnar Hand Sensory Deficit Guyon's Canal Intrinsic Ulnar Atrophy
Ulnar Sensory Deficit
Extrinsic Weakness
DCU Deficit Cubital Tunnel Intrinsic Ulnar Atrophy
Intrinsic Median Atrophy
Normal Sensation C8,T1 Root / Spinal Cord Sensory vs Motor
Intrinsic vs Extrinsic
Median vs Ulnar Examination Patient Evaluation Brachial Plexus Examination Clinical Examination Examination Worksheet Lower Plexus Injury (-) finger flexion, AIN, median intrinsics, ulnar ex/intrinsics, ulnar sensation (+) shoulder, elbow, wrist/finger extension, pronator, FCR (-/+) EPL Radial Median Ulnar Jumping the Gap in Spinal Cord Injury Supercharging the Injured Nerve Nerve Transfers for Restoring Function Stretch Transection Avulsion Transverse Ganglion Anatomy Supra (Pre) - ganglionic Injury Infra (Post) - ganglionic Injury Dorsal Root Ganglion - Sensory Cell Body
Ventral Horn - Motor Cell Body Types of Ganglionic Nerve Injuries Sensory - Normal
Motor - Abnormal Electrical Studies (EMG/NCS) Sensory - Abnormal
Motor - Abnormal Electrical Studies (EMG/NCS) 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 NIH - 2R01NS05170606A1
The Effects of GDNF on Peripheral Nerve Regeneration
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