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2012 QMP - Master Course Nerve Transfers 101: A Primer

Comprehensive Review of Neurosurgery; 7/8/2012
by

Andrew Yee

on 7 January 2013

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Transcript of 2012 QMP - Master Course Nerve Transfers 101: A Primer

Classification of Nerve Injuries Supercharge
Nerve Transfers (+) (+) Nerve Transfers Recipient Nerve Distal Results of Nerve Grafting Results of Nerve Transfers Medial Pectoral to Musculocutaneous
Nerve Transfer Thoracodorsal to Axillary
Nerve Transfer 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 Nerve Transfers Restoration of Elbow Function Restoration of Shoulder Function Spinal Accessory Nerve
C7 (Pectoral) to spinal accessory transfer

Suprascapular Nerve
Spinal accessory to suprascapular transfer

Axillary Nerve
Medial triceps to axillary transfer
Medial pectoral to axillary transfer
Thoracodorsal to axillary transfer

Long Thoracic Nerve
Double-level transfer
C7 (Pectoral) to long thoracic transfer
Thoracodorsal to long thoracic transfer

Intercostal to long thoracic transfer Musculocutaneous Nerve
Double fascicular transfer
Thoracodorsal to musculocutaneous transfer
Medial pectoral to musculocutaneous transfer

Triceps Brachii Nerve
Flexor carpi ulnaris to medial triceps transfer Spinal Accessory to Suprascapular Transfer (ETE - Posterior Approach) Spinal Accessory to Suprascapular Transfer (ETS - Anterior Approach) Medial Triceps to Axillary Nerve Transfer Double Fascicular Nerve Transfer Flexor Carpi Ulnaris to Triceps Brachii Nerve Transfer Double Fascicular Transfer Median and Ulnar Anatomy Double Fascicular Transfer Double Fascicular Transfer Median and Ulnar Anatomy Median and Ulnar Anatomy FCU Fascicle Stimulation FCR Fascicle Stimulation Post-operative Results Double Fascicle Nerve Transfer Ulnar and Radial Anatomy Nerve Transfer Donor Recipient Donor Recipient Donor Recipient Recipient Donor Donor Donor Recipient Recipient Donor Donor Recipient Recipient Post-operative Results FCU to Medal Triceps Nerve Transfer Motor Transfer Sensory Transfer Radial Sensory Component to Superior Lateral Cutaneous Nerve Transfer (N) suprascapular Recipient (N) spinal accessory Donor Acromion Medial Border / Spine of Scapula Spine Suprascapular Notch
(Suprascapular Nerve) Spinal Accessory Nerve Recipient Donor Recipient Recipient Recipient Donor Donor Motor End-to-side
Neuroectomy Proximal Crush I. II. Spinal Accessory to Suprascapular Nerve Transfer End-to-end Motor End-to-side sacrifice lower trapezius backfill trapezius by reinnervating entire muscle Donor Recipient Recipient Donor Donor Recipient Neuroectomy Proximal Crush Post-operative Results Post-operative Results Medial Triceps to Axillary Nerve Transfer
Spinal Accessory to Suprascapular ETE Nerve Transfer Bands of Fontana Motor Branch Sensory Branch Motor Regeneration Femoral Nerve End-to-side Regeneration With Injury Crush Partial Neurectomy I. II. Types of End-to-side III. End-to-side Proximal Crush Neurectomy Fluorescence End-to-side (Atraumatic) End-to-side (Compression) End-to-side (Epineurotomy) Transgenic GFP Models Compression Epineurotomy Atraumatic Regenerative Sprouting Experimental Studies Pannucci C, et al . End-to-side nerve repair: review of the literature. Restor Neurol Neurosci. 25:45-63, 2007. Radial Nerve Stimulation Donor Recipient Recipient Donor Donor Recipient Recipient Donor Median to Radial Nerve Transfer 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 3rd to 1st Webspace Nerve Transfer DCU to Critical Median Sensory Nerve Transfer 3rd Webspace to Ulnar Sensory Nerve Transfer 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 FCR to Pronator Teres Nerve Transfer Complete Median Nerve Injury AIN Palsy 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) critical sensation non-critical sensation
preserving distal donor sensory nerves (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 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 I II IV III V VI Donor Recipient End-to-end Donor Recipient Supercharge
End-to-side Anchorage, AK Susan E. Mackinnon, MD

Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO Nerve Transfers 101: A Primer 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 2012 QMP Reconstructive Surgery Symposium Supercharging the Injured Nerve Master Class 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 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 Post-operative Results Functional Recovery - 2 Year Anterior Interosseous (PQ) to Ulnar Motor Nerve Transfer 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 MOTOR SENSORY NIH - 2R01NS05170606A1
The Effects of GDNF on Peripheral Nerve Regeneration 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 Double Fascicular Nerve Transfer Results
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