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Patient G.S.

Patient G.S. Zachary R. Barnard UCSD Neurosurgery Sub-intern September 2012. Chief Complaint. 22 year old RHM presents with flaccid paralysis of left upper extremity after a motorcycle accident 6 months ago. History of Present Illness.

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Patient G.S.

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  1. Patient G.S. Zachary R. Barnard UCSD Neurosurgery Sub-intern September2012

  2. Chief Complaint 22 year old RHM presents with flaccid paralysis of left upper extremity after a motorcycle accident 6 months ago

  3. History of Present Illness • 6 months PTA: patient presented to UCLA medical center with a GCS of 3 after being thrown 40 feet from his motorcycle that collided with a motor vehicle • Multiple surgeries • Exploratory laparotomy • Thoracotomy • Splenectomy • Ligation of multiple bleeding intercostal vessels • Reconstruction of diaphragmatic rupture • Left nephrectomy • Repair of colon laceration • Neurologically • Right frontal hemorrhagic contusion • Evidence of DAI • EVD placement

  4. History of Present Illness • 4 months PTA: patient was discharged from UCLA medical center • 2 months PTA: patient f/u with neurosurgery at UCLA for evaluation of left arm paralysis • Neuro exam: • Motor- Complete paralysis of his deltoids, biceps, triceps, pectoralis, wrist flexors, wrist extensors, and intrinsic hand muscles. • Sensory was showed patchy sensation proximally and no sensation distally • Referred to Dr. Brown for evaluation

  5. Left brachial plexus Imaging T2 MRI-fat suppressed C6-C7 C7-T1 T1-T2

  6. Left brachial plexus Imaging T2 MRI-fat suppressed

  7. EMG: Left arm • Severe C4-T1 radiculopathy • Evidence of C7-T1 nerve root avulsions • C6 nerve root likely not avulsed • C5 nerve root avulsion indeterminate

  8. Operations Stage 1: • Brachial plexus exploration with neuroma resection • Anterior and middle scalenectomy • C5-C6 nerve grafting to posterior cord and suprascapularnerve • Bilateral sural nerve harvest Stage 2: • C5 nerve root connection to suprascapular nerve through sural nerve graft Stage 3: • Motor intercostal of 3,4,5,7 grafted to musculocutaneous nerve • Sensory intercostal of 3,4 grafted to median nerve • Motor intercostal 7,8 to lateral antebrachial cutaneous nerve graft • Lateral antebrachial cutaneous nerve graft to extensor carpi radialislongus and brevis

  9. Post-operative Course • Patient had an unremarkable post-operative course • Drains were removed and patient was discharged home with wound care on post-operative day eight

  10. “Peripheral nerve surgery and nuances in regenerative medicine”

  11. Background • Earliest possible reconstruction • Detailed neurological exam • MRI imaging • EMG • Elbow flexion usually first priority, followed by shoulder abduction/external rotation/stability, then hand sensation

  12. Nerve transfer vs. nerve repair for upper brachial plexus injury • Yang, et al 2012 • Systematic review • 33 studies included • 399 nerve transfers • 99 nerve repairs • 117 transfers + repairs • Inclusions • Age > 18, f/u > 6 months, injury (avulsion/rupture), function (elbow flexion or shoulder abduction) • Outcomes • Rates ratio • MRS elbow flexion & Should abduction • Outcomes/Results

  13. Ciliaryneurotrophic factor promotes reinnervation of musculocutaneous nerve • Aim: • Assess motor vs. sensory fibers in ability to sprout in end-to-side grafting with ciliaryneurotrophic factor (CNTF) • Model: • 24 Rats MS to Ulnend-to-side graft • Endpts: • Measure % motor neurons • Fn biceps (EMG) • Results: • PBS motor neurons 9.9% • CNTF motor neurons 17% • EMG • Biceps brachii larger amplitude of contract in CNTF compared to PBS • Flexor carpi ulnaris no difference

  14. Musculocutaneous nerve graft enhancement with VEGF • Aim: • Assess phVEGF ability to reinnervate end-to-end, end-to-side nerve grafts • Model: • 42 Rats, cut end of nerve transfected with virus • Endpts: • Measure increase in motor neuron percent by diameter of neuron

  15. BDNF and GDNF in nerve regeneration • Brain-derived neurotrophic factor (BDNF) • Glial cell-derived neurotrophic factor (GDNF) • Electrical stimulus • Rolipram (PDE4 inhibitor) anti-inflammatory

  16. Summary • Clinical rule of “seven seventies” for traumatic brachial plexus lesions • Based on 1068 patients (Siqueira et al, 2011) • 70% due to MVCs • Of these, 70% motorcycles • Of these, 70% multiple injuries • Overall, 70% supraclavicular lesions • Of these, 70% at least one root avulsion • Of these, 70% avulsion C7, C8, or T1 • Of these, 70% persistent pain

  17. Summary • Peripheral nerve surgery still in infancy • Conclusion on best treatment difficult due to lack of randomized controlled trials • Lots of basic science possibilities, but need more translational work

  18. Conclusions “A certain excessiveness seems a necessary element in all greatness” -Harvey Cushing

  19. References • 1. Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY. Current concepts of the treatment of adult brachial plexus injuries. The Journal of hand surgery. 2010;35(4):678-88; quiz 88. Epub 2010/04/01. doi: 10.1016/j.jhsa.2010.01.021. PubMed PMID: 20353866. • 2. Yang LJ, Chang KW, Chung KC. A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury. Neurosurgery. 2012;71(2):417-29; discussion 29. Epub 2012/07/20. doi: 10.1227/NEU.0b013e318257be98. PubMed PMID: 22811085. • 3. Bao YF, Tang WJ, Zhu DQ, Li YX, Zee CS, Chen XJ, et al. Sensory neuronopathy involves the spinal cord and brachial plexus: a quantitative study employing multiple-echo data image combination (MEDIC) and turbo inversion recovery magnitude (TIRM). Neuroradiology. 2012. Epub 2012/08/28. doi: 10.1007/s00234-012-1085-x. PubMed PMID: 22922867. • 4. Lee SK, Wolfe SW. Nerve transfers for the upper extremity: new horizons in nerve reconstruction. The Journal of the American Academy of Orthopaedic Surgeons. 2012;20(8):506-17. Epub 2012/08/03. doi: 10.5435/JAAOS-20-08-506. PubMed PMID: 22855853. • 5. Siqueira MG, Martins RS. Surgical treatment of adult traumatic brachial plexus injuries: an overview. Arquivos de neuro-psiquiatria. 2011;69(3):528-35. Epub 2011/07/15. PubMed PMID: 21755135. • 6. Fox IK, Mackinnon SE. Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders. Plastic and reconstructive surgery. 2011;127(5):105e-18e. Epub 2011/05/03. doi: 10.1097/PRS.0b013e31820cf556. PubMed PMID: 21532404. • 7. Dubovy P, Raska O, Klusakova I, Stejskal L, Celakovsky P, Haninec P. Ciliaryneurotrophic factor promotes motor reinnervation of the musculocutaneous nerve in an experimental model of end-to-side neurorrhaphy. BMC neuroscience. 2011;12:58. Epub 2011/06/24. doi: 10.1186/1471-2202-12-58. PubMed PMID: 21696588; PubMed Central PMCID: PMC3224149. • 8. Haninec P, Kaiser R, Bobek V, Dubovy P. Enhancement of musculocutaneous nerve reinnervation after vascular endothelial growth factor (VEGF) gene therapy. BMC neuroscience. 2012;13:57. Epub 2012/06/08. doi: 10.1186/1471-2202-13-57. PubMed PMID: 22672575; PubMed Central PMCID: PMC3441459. • 9. Gordon T. The role of neurotrophic factors in nerve regeneration. Neurosurgical focus. 2009;26(2):E3. Epub 2009/02/21. doi: 10.3171/FOC.2009.26.2.E3. PubMed PMID: 19228105.

  20. Acknowledgements • Dr. Brown • Dr. Curtis • Neurosurgery Faculty • Neurosurgery Residents • Eric Lin

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