Loading presentation...

Present Remotely

Send the link below via email or IM


Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.


2012 CRN - Acute Nerve Injury and Repair - Part 1

Comprehensive Review of Neurosurgery; Part 1 - Peripheral Nerve Surgery; 5/20/12

Andrew Yee

on 6 January 2013

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of 2012 CRN - Acute Nerve Injury and Repair - Part 1

Nerve Grafting Nerve Allograft Conduit and Acellularized Allograft Nerve Transfers End-to-end End-to-side Supercharge
End-to-side 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 Sensory ETS Nerve Transfers Motor ETS Nerve Transfers Rudimentary Sensation Pain Management Backfilling Donor Muscle Regenerative Sprouting Spontaneous Collateral Sprouting 1. Neuroma Pain 2. Hyperalgesia Pain Surgical Management Proximal Transposition Proximal Transposition and ETS Nerve Transfer Bridging the Gap Requirements: Proximal Crush and Neurectomy Dorsi MJ, et al. The tibial neuroma transposition (TNT) model of neuroma pain and hyperalgesia. Pain. 138:320-334, 2009. C5,6 Nerve Palsy - 1st and 2nd Webspace Deficit 3rd to 1st Sensory Nerve Transfer Anterior Approach - Spinal Accessory to Suprascapular ETS Nerve Transfer Motor End-to-side Neurectomy Proximal Crush 2nd Degree Nerve Injury Reinnervation - Backfilling Ray WZ, et al. Functional recovery following an end to side neurorrhaphy of the accessory nerve to the suprascapular nerve: case report. Hand (NY). 5(3):313-7, 2010. 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 Donor Deficit Sural Cable Crafting Nerve Grafting Post-operative Outcome 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 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 Comprehensive Review of Neurosurgery Part I - Peripheral Nerve Surgery
Full transcript